
	Introduction

	CPPI

	PAHAS

	PAS

	HEDIS

	CAHPS

The Patient Assessment Survey (PAS) Group Survey Information Sheet

Background

Since 2001, the California Cooperative Healthcare Reporting Initiative (CCHRI), a statewide collaborative of health plans, provider organizations, and purchasers, has conducted an annual survey to assess patient experience with the care delivered by the patient's medical group. The Patient Assessment Survey (PAS) reflects the commitment of plans, purchasers and provider organizations to the joint administration of a statewide patient experience survey, in an effort to reduce redundancy and confusion regarding measurement and public reporting of performance results.

PAS is conducted under the auspices of the California Collaborative Healthcare Reporting Initiative, with oversight provided by the CCHRI Executive Committee and guidance from the CCHRI PAS Project Committee - composed of representatives of each participating health plan and ten physician groups. In 2009, eight major California health plans, 145 unique physician organizations (reporting on 184 units), and the 50 purchasers of care represented by the Pacific Business Group on Health (PBGH) collaborated in the PAS project. The 2009 participating groups served 11.6 million commercially insured HMO and POS patients, or 94.4% of the total HMO/POS commercial population in California. The participating health plans in 2009 were Aetna, Anthem Blue Cross, Blue Shield, CIGNA Health Net, Kaiser Foundation Health Plan, PacifiCare Health Systems (UnitedHealthcare), and Western Health Advantage.

PAS in the IHA Pay for Performance Program

Each year a subset of question items from the PAS survey are selected for inclusion in the IHA Pay-for-Performance (P4P) program. Like other P4P measurement domains, IHA puts forth for public comment the potential measures it will include from the PAS. The P4P Steering Committee approves all final measures included in the P4P measurement set by year end, with significant input from the Technical Committee and stakeholders during the public comment period. The PAS measures selected for payment, their associated questions and weights can be found on the IHA website at www.iha.org, organized by measurement year. It is ultimately up to each health plan to determine thresholds for payment for P4P patient experience measures.

Physician Group Eligibility

All physician groups that serve commercially-insured, adult HMO and POS patients are eligible to participate for Measurement Year 2009.

Unit of Analysis

The unit of analysis is in most cases the unique physician group. However, some physician groups elect to survey multiple subunits and, in those cases, those smaller reporting units are the unit of analysis.

Survey Instrument

PAS builds off of a national research effort to create a standardized tool for measuring patient experience with care received in the ambulatory care setting. Specifically, the PAS significantly overlaps with the Clinician and Group CAHPS survey (CG-CAHPS) that is under development through a collaboration between the Agency for HealthCare Research and Quality (AHRQ), RAND, Harvard University and the American Institute for Research (AIR). The CAHPS team submitted CG-CAHPS to the National Quality Forum (NQF) in July 2007 for its endorsement. Differences between the emerging national CG-CAHPS survey and the California PAS survey reflect issues that are of particular interest to the California stakeholders and/or that support the IHA Pay-for-Performance program. As the national CAHPS team continues its work to refine the CG-CAHPS survey, CCHRI will continue to monitor this work to stay aligned with what is anticipated to become the national standard. One distinction is that PAS has developed both PCP and Specialist versions of the survey. These two versions overlap substantially.

Performance Domains

The key performance domains assessed in P4P include:

Patient access to care (primary and specialty, non-urgent and urgent)
Coordination of care
Doctor-patient interactions (i.e., communication)
Office staff
Health promotion
Specialty care access and ratings
Overall ratings of care

Patient Population Surveyed

A sample of 900 adult, commercially-insured HMO and POS patients who: 1) have had at least one visit between January and October of the measurement year; and 2) are enrolled in the medical group as of October 31 of the measurement year, are randomly sampled from each group. The sample is stratified, with 450 of the patients being drawn from patients with visits with their assigned PCP, and the other 450 patients being drawn from those with visits with a specialist.

Physician Group Registration

For the 2009 Measurement Year, CCHRI sent invitations to all physician groups operating in California that have at least 1,000 managed care enrollees.

Registration for the 2010 Patient Assessment Survey closed on September 25th.

During the registration process, groups were provided with information on various survey options and the associated fees. Groups were required to provide up-to-date contact information as well on data on member enrollment and geographic locations served. Groups were also required to agree to the terms outlined in the CCHRI PAS Participation Agreement and to download, sign and return a Business Associate Agreement to the survey vendor for the project, the Center for the Study of Services (CSS).

If physician groups have any questions about the registration process, they should contact Julie France at jfrance@pbgh.org or at 714.735.8754.

In addition to signing up to participate in the PAS Physician Group Survey, groups had the opportunity to elect supplemental survey options, including:

Surveying distinct sub-units or practice sites of the medical group as separate reporting units, each with a unique sample of 900 patients.
Alternative language surveying, in which groups elect to double stuff the patient survey packages with a survey translated into an alternative language of their choice (Spanish, Chinese, or Vietnamese). Double stuffing facilitates responses by patient populations who may not be fluent in English. (See Fee Schedule at www.cchri.org/programs/programs_pas.html for additional fees)
Doctor Survey participation, in which groups elect to conduct additional surveying at the physician level using the PAS survey instrument, processes and methods. This supplemental project is designed to facilitate group's quality improvement work. In addition, pediatricians may be included in the doctor survey process. (See Fee Schedule at www.cchri.org/programs/programs_pas.html for additional fees.) In 2009, 33 physician groups elected to participate in the Doctor Survey in addition to the Group Survey. In the context of the IHA P4P program (Systemness Domain, measure 5), POs can earn 4 points for measuring physician level patient experience and/or clinical performance, reporting it to physicians, and offering financial incentives or other incentives of monetary value based on performance.
Provider After Hours Access Survey participation, in which telephone interviews are conducted to assess protocols around after hours care for a sample of primary care physician offices. (No additional fees)

Physician Group Requirements

In addition to formally registering, groups must adhere to the following requirements. Failure to meet the deadlines will forfeit the group's participation in the PAS project and thus eligibility for any P4P bonus dollars associated with the PAS performance measures.

Register to participate via http://www.cchri.org/pas_registration no later than September 25th, 2009.
Sign off on the Participation Agreement at the time of registration.
Submit (or confirm) the physician group logo and executive signature, to be printed on the survey cover letter and instrument by October 9, 2009 here.
Download, sign and mail BAA to survey vendor by October 9, 2009. BAA may be found here.
Provide accurate information on the group's coding practices and provider specialties, as requested in an online survey hosted by the survey vendor by October 9th, 2009 here.
Submit data files on all eligible patients, patient visits and providers, from which the patient sample will be drawn from November 2 through November 20, 2009 here. All data submissions must meet the data quality criteria identified by the PAS project. An inability to meet the defined criteria will forfeit a group's participation in PAS (November 2 - November 20th, 2009).
Pay participation fees associated with the survey options elected by the physician group by January 15, 2010.

Sampling

After final approval of the data files submitted by each group, the survey research firm draws a total sample of 900 patients for each reporting unit. The sample is stratified by visits to Primary Care Physicians (n=450 PCP visits) and Specialty Care Physicians (n=450 specialist visits), and within strata, patients are randomly selected. For patients with an assigned PCP, the visit must be with the assigned PCP to be eligible for inclusion in the sample. Patients without assigned PCPs are "assigned" by the survey vendor to the most frequently visited PCP. In drawing the sample of patients, only one eligible adult from each household is included.

To increase the likelihood of responding, sampling is prioritized by the most recent date of visit. Patient visits are grouped into three periods: January-April, May-July and August-October. Starting with the most recent period (August-October) visits are randomly selected from the enrollment files of each group.

Survey Fielding

The standard survey protocol consists of two mailed surveys, including a cover letter which outlines an option to complete the survey via the survey vendor web site using a unique web ID contained in the letter. The cover letter is printed using the logo of the patient's physician group and signed by the group's medical director. The first mailing occurs in late January. The second occurs in late February and is sent only to those patients from whom there is no prior response (via web or mail). Those patients who do not respond after the second mailing are contacted via phone in late March. Mail, web and phone interviews are available in English and Spanish for all patients and all mailed cover letters include a message in Spanish inviting patients to request a Spanish version of the survey via a toll-free number. Groups are also provided the option to field the survey in English and an alternative language (Chinese, Spanish, or Vietnamese). Patients receiving the alternative language survey receive a cover letter in English with a translation in the alternative language printed on the back of the letter, in addition to a copy of the survey instrument in the alternative language.

Response File Preparation

Upon completion of the survey fielding, the survey vendor conducts data cleaning, including removing duplicate interviews, merging the response data with the original sample data, and conducting consistency checks between question items. Response data files from mail, web and telephone interview sources are cleaned for out-of-range responses for each question. Cases with out-of-bound ages (<18) are dropped from analysis. All responses are kept for analysis in which the patient either confirms the physician visit or, for PCP patient interviews, provides the name of another PCP in the physician group and confirms that they had had a visit with the physician in the past year. If the respondent indicates a physician that cannot be matched to the physician group's provider file, then the respondent's survey is dropped from analysis.

Analysis of the Survey Data

Each medical group's results are adjusted for patient case-mix to control for differences across physician groups. In 2009, the case-mix adjustment model controlled for:

Age
Gender
Education level
Race/ethnicity-primary language of respondent
Presence of chronic conditions
Single item physical health status
Single item mental health status
Specialty type of physician that patient rated (44 categories)
Survey response mode (mail, internet, or phone)
Language in which survey was completed

Reports

Groups receive the following reports of their results:

P4P Results (May): Each group receives its own results on the P4P set of items, along with a set of percentile cut points that demonstrate statewide performance.

Medical Group Report (June): Each group receives a report which displays their results for all question items in various formats and as compared to other physician groups in their region. This report also describes all survey methods and processes.

Excel File (June): Each group receives an Excel file which provides comparative results on each question items for all medical groups in their region.

Raw Data File (June): Each group receives a file with the de-identified raw survey data for all patient respondents.

Additionally, the results of the survey are made publicly available for use by consumers through the California Department of Managed Health Care's Office of the Patient Advocate consumer website (www.opa.ca.gov/report_card) each October. Performance results will not be publicly reported for any overall rating question or composite that achieves a reliability score of less than 0.70.

Key Timelines

September 10, 2009: Registration site live.
September 10, 2009: Data checking tool available on the survey vendor's website via the CCHRI website.
September 25, 2009: Registration deadline. Participation agreement due (via electronic consent during the registration process).
October 9, 2009: Deadline for groups to submit/confirm group logos/signatures, complete online survey on coding practices and physician specialties and mail signed BAS.
November 20, 2009: Data files and attestation due to survey vendor.
January-April, 2010: Survey fielding.
May 2010: Results for P4P items to groups, plans, and IHA.
June 2010: Medical group report including all survey items, comparative results, and raw data to medical groups.
July 2010: Individual doctor report including all survey items, comparative results, and raw data to medical groups.