Preparing for OAS CAHPS

In this episode of the Advancing Surgical Care Podcast, ASCA Chief Executive Officer Bill Prentice and ASCA Director of Education & Clinical Affairs Gina Throneberry discuss the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey, a postoperative patient survey developed by the Centers for Medicare & Medicaid Services (CMS). Beginning in January 2025, OAS CAHPS will become a mandatory part of Medicare’s Ambulatory Surgical Center Quality Reporting (ASCQR) Program, and ASCs will be required to use a CMS-approved, third-party vendor to administer the survey to their patients. In this short, but highly informative program, Prentice and Throneberry discuss the origins of the OAS CAHPS Survey, its content, threshold requirements and the importance of hiring a vendor and implementing the survey well in advance of January 2025.

Transcript

Narrator:   0:01
Welcome to the Advancing Surgical Care Podcast brought to you by ASCA, the Ambulatory Surgery Center Association. ASCA represents the interests of outpatient surgery centers of every specialty and provides advocacy and resources to assist them in providing safe, high-quality, cost-effective patient care. As with all of ASCA’s communications, please check to make sure you are listening to or viewing our most up-to-date podcasts and announcements.

Bill Prentice:   0:27
Hello, and welcome to the Advancing Surgical Care Podcast. My name is Bill Prentice and I’m ASCA’s CEO. Today I’ve asked Gina Throneberry, ASCA’s director of education & clinical affairs, to join me on the podcast to talk about the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems, or OAS CAHPS, a postoperative patient survey that was developed by the Centers for Medicare & Medicaid Services, or CMS. Development of this survey instrument began back in 2012, and with ASCA’s input it evolved over several years and ASCs should know that it will become mandatory starting for hospital outpatient departments this coming January in 2024 and for surgery centers in January of 2025. Now conceptually, ASCA was supportive of the notion of surveying patients to learn more about their experience in surgery centers and hospital outpatient departments. But at the same time, we stressed with CMS the importance of maintaining a clear distinction between clinical outcomes and patient likes and dislikes, and not letting the survey elevate superficial nonclinical issues. Now, while ASCA did have some input into the early development of survey, I have to be honest that many of our recommendations did not make it into the final survey instrument. From ASCA’s perspective, the survey that CMS settled on is far from perfect. It’s too long for starters, with a total of 34 questions that cover the gamut of a patient’s experience from preoperative recovery, as well as their assessments of personnel and the facility itself. Still, the OAS CAHPS Survey can still produce some valuable data for individual surgery centers to assess patient satisfaction and for the entire ASC community to demonstrate patient preference for the care we provide, particularly as we compare to the patient experience in hospital outpatient departments. So, Gina, welcome and let’s discuss what administrators in ASC staff need to know about the OAS CAHPS Survey.

Gina Throneberry:   2:29
Thanks, Bill and let’s start this discussion.

Bill Prentice:   2:33
Great. Well, as I mentioned a moment ago, it will be mandatory for ASCs to start administering the OAS CAHPS Survey to patients beginning in 2025. As we both know, ASC administrators are extremely busy and often stretched to their limits with regulatory and clinical compliance issues. So why is it important for surgery center staff to familiarize themselves with OAS CAHPS now, this far ahead of the January 2025, mandatory implementation date?

Gina Throneberry:   3:01
It’s very important to start early because there are many parts and pieces to this implementation. This survey can only be administered by CMS approved third party vendor. A list of these vendors is located on the OAS CAHPS’ website. Your ASC will need to have a discussion with your potential vendor to ask questions such as pricing, what CMS approved mode do they offer, are the reports look like the ASC will receive and length of time to onboard your ASC. Please do not think that you can begin this process on December 31 of 2024 and expect everything to be up and running the next day in time for the mandatory period. That is not going to happen. Plus, we’ve been told by some of the CMS approved vendors that they will not have the staffing to take a large influx of ASCs that procrastinate and wait until the very last minute.

Bill Prentice:   3:55
Right, so important to get in early with your vendor, get to know them, let them get to know you, familiarize yourself with this process in order to make sure that you’re doing it correctly come January 2025 and my understanding is that surgery centers who have already begun surveying patients ahead of this deadline can submit their early results to CMS but aren’t required to do so. So, Gina, the added benefit I think of starting early is you get to see these survey results before they have to be made public. That sounds like one more good reason why to get an early start on this. Am I correct on that?

Gina Throneberry:   4:32
Yes, Bill, you’re correct. ASCs might not realize certain processes in certain areas of the ASC are not what they should be and having these results from the survey can help point out these processes for the ASC to resolve.

Bill Prentice:   4:46
Great. So, Gina almost every ASC is already using a patient satisfaction survey of some kind right now. And by and large from what we hear the results are very positive. However, surgery center staff also tell us that getting patients to complete a survey requires a lot of effort. That being the case, it might be helpful for you to talk about the number of surveys that a surgery center will need to complete in a calendar year under this OAS CAHPS process, and the different methods they can use to collect that data.

Gina Throneberry:   5:21
Sure, ASCs need to have 200 completed surveys over a 12-month period. The current administration modes of the survey are mail only, telephone only, mixed mode, which is mail with telephone follow up, an electronic version with mail follow up, an electronic with telephone follow up. However, currently, CMS has not approved an electronic only survey, they are presently five approved modes for this survey.

Bill Prentice:   5:53
Right. And we’ve been really pushing them over the years to have an electronic only, recognizing that would be much simpler for a surgery center to use, and more likely to get the results that those 200 responses that are required, correct?

Gina Throneberry:   6:08
That is correct. Yes, we comment on that every period and fingers crossed one day we’ll have one.

Bill Prentice:   6:15
Because the other complicating factor, as we’ve talked about is the length of this survey, having that many questions and trying to get a patient to answer all of them to complete that survey is going to be a bit of a process. That said, I understand that the surgery center sees a place where a question that’s not being asked for which they’d like information from the patient. They can actually add some questions to the survey if they’d like as long as they have all the questions that are mandated included, they could add more if they like, correct?

Gina Throneberry:   6:45
Yes, that’s correct, and ASC can add up to 15 supplemental questions. However, I do caution ASCs to please do the math before they start adding more questions. As mentioned, 34 questions in the survey, plus an additional number of questions will make the survey even more lengthy for the patient to complete. Also, if your ASC is presently doing some type of patient satisfaction survey, whether that is administered by your ASC or another vendor, you would need to decide what to do with this survey. Do you transition a few questions to the OAS CAHPS Survey? Do you keep both surveys? If you do keep both surveys, there is a high probability the patient will not complete those surveys and they will cannibalize one another. This is another reason to start planning now for the mandatory implementation period that will start in January of 2025.

Bill Prentice:   7:37
Sound Advice. But Gina we need to pause for a moment to hear a brief message from our podcast sponsor. Standby and we’ll be right back.

Narrator:   7:45
This episode of the Advancing Surgical Care Podcast is brought to you by AMSURG, a national leader in the strategic and operational management of ambulatory surgery centers. AMSURG partners with more than 2,000 physicians and health systems and more than 250 ASCs operating in 34 states. Learn more by visiting amsurg.com.

Bill Prentice:   8:06
Gina, another common question that members have often asked is, “What do we know about how CMS intends to use this OAS CAHPS data that ASCs will be reporting?” What can you tell us about that at this point?

Gina Throneberry:   8:19
Yes, right now, CMS is posting the data as its own measure on the Care Compare website and we expect that data to continue to grow as more ASCs come on board in doing the survey.

Bill Prentice:   8:33
Right and then as with mostly this, these, you know, elements required by CMS, there’s usually a penalty for noncompliance. If an ASC fails to comply with the OAS CAHPS Survey requirement in 2025, what’s the result?

Gina Throneberry:   8:48
So, the OAS CAHPS Survey quality measure is part of the entire quality measure reporting program. If data for this measure or any other measure is not reported, an ASC will receive a two percentage point reduction of their annual payment update.

Bill Prentice:   9:06
So, a pretty stiff penalty for not complying, yet another reason why our surgery center members should really start to get working on this project right now. So, Gina, let’s talk about ASCA resources and selecting a survey vendor. The ASCA website provides all the details we’ve discussed here as well as links to other helpful information like the list of CMS-approved survey vendors. Right now, there are 15 approved vendors and all and they offer different features in different pricing. I will note that ASCA has worked with Press Ganey, a well-known provider in this space, to offer ASCA members a significant discount on their customary pricing. It may be worth comparing their offerings to others. So, Gina, is there anything else you’d like to add about the vendor selection process?

Gina Throneberry:   9:53
Sure. I would recommend again starting now and doing your homework to find the vendor that best fits the needs of your ASC. Earlier in the podcast I outlined some questions to ask the vendor, so when you make that call to the vendor, have your questions listed on a piece of paper so you will know you’ve covered all your questions. There are also some good resources listed on the ASCA website. And again, the OAS CAHPS website, I would highly recommend bookmarking that on your computer because you will need to use that frequently for any questions you might have about this quality measure.

Bill Prentice:   10:28
Well great. And, you know, obviously, as we learn more, or if we have something else pops up, we’ll be adding that to our ASCA’s resources. So, I really encourage our members to use our new and improved ASCA website to get answers to these questions. So, Gina, thank you for coming on the podcast and helping our members understand OAS CAHPS and the need to start the work of identifying and select a vendor for this upcoming mandatory element of the ASC Quality Reporting Program, never too soon to start looking into that selection process. And if anyone has any questions, of course, they are free to reach out to us. We’re happy to help as they embark on this new element of our Quality Reporting Program. And finally, before closing, I would like to once again thank our podcast sponsor AMSURG, a leading ASC management company with more than 250 ASC partners in 34 states. To learn more about them, visit amsurg.com.