Participation
What are the practice requirements for the PEC Survey?
Please refer to Section 7.03 (or 7.04) of the PCF Participation Agreement: Section 7.03 Patient Experience of Care Measure:
a. The PCF Practice shall procure a CMS-approved vendor to conduct the Consumer Assessment of Healthcare Providers & Systems (CAHPS®), also known as the Patient Experience of Care Surveys (PECS) ("PEC Survey" hereafter). CMS will notify the PCF Practice at least 120 days in advance of when the PCF Practice must begin conducting the PEC Survey, and CMS will make available to the PCF Practice a list of approved PEC Survey vendors on the same date or sooner, in a form and manner to be determined by CMS.
b. The PCF Practice shall:
1. Contract with a CMS-approved PEC Survey vendor by a date to be determined by CMS, and authorize such vendor to submit information, including the PCF Practice’s PEC Survey results, to CMS on behalf of the PCF Practice.
2. Submit a patient roster for all patients to CMS by a date and in a manner to be specified by CMS. CMS will validate the roster and provide the roster to the survey vendor directly;
3. Pay for the surveys and ensure that the survey results are transmitted to CMS by a date and in a manner to be specified by CMS; and
4. Ensure that the vendor adheres to the questionnaire, survey protocol, and format for submitting PEC Survey results to CMS.
c. If the vendor does not timely submit the PCF Practice's PEC Survey results, or if the vendor submits inaccurate, unusable, or otherwise compromised data, CMS will assign the PCF Practice a 0 for its yearly PEC Survey score, and the PCF Practice will not meet the Quality Gateway for that Performance Year, pursuant to Section 5.03(b)(1), and CMS may take remedial action against the PCF Practice pursuant to Article 15.
Will the PY 2025 PEC Survey be fielded?
No. As of March 2025, the CMS Innovation Center announced their decision to conclude the Primary Care First (PCF) model one year earlier than originally planned. As a result of this accelerated timeline, the PEC Survey for the 2025 performance year has been cancelled. PCF practices are no longer required to authorize a vendor or submit patient rosters. There is no additional practice action, such as submitting a patient roster or authorizing a vendor, required for practices.
For more information about the Center's decision, please see the fact sheet linked below:
Fact Sheet: CMS Innovation Center Announces Model Portfolio Changes to Better Protect Taxpayers and Help Americans Live Healthier Lives | CMS
Who pays to administer the CAHPS survey (Patient Experience of Care Survey)?
The PCF PEC Survey protocols follow the same model as other CAHPS surveys, such as the CAHPS for Merit-based Incentive Payment System (MIPS), where providers contract with approved survey vendors for the data collection and implementation of the survey. CMS has adopted standardized survey protocols that allow for varying survey costs and ensured that the approved vendors are trained to implement these protocols consistently. However, CMS does not dictate the pricing for the approved survey vendors.
If my practice site is in an Accountable Care Organization (ACO) does the CAHPS survey meet the need for the PEC Survey requirement?
Practice sites that are dual participants in an ACO and PCF must meet all quality reporting requirements of the ACO and for PCF. The CAHPS for MIPS survey is part of the ACO quality standard and should be fielded as required. PCF practice sites were also required to submit a patient roster for sampling and to engage a vendor for the PCF PEC Survey administration as required for the PCF quality reporting.
What is the difference between CAHPS for MIPS and the PCF PEC Survey?
CAHPS for MIPS is based on the Clinician and Group (CG-CAHPS) survey and includes additional program specific survey questions. The PCF PEC Survey, while based on a combination of questions from the CG-CAHPS v.3.1 and CAHPS Patient-Centered Medical Home Item Set v. 3.0., is designed specifically for the PCF Model. Practices that are dual participants in an ACO and PCF must meet all quality reporting requirements of the ACO and for PCF. The CAHPS for MIPS survey is part of the ACO quality standard and should be fielded as required.
Patient overlap between PCF PEC Survey and CAHPS for MIPS is possible. To avoid imposing on patients, CMS strongly encourages practice sites to refrain from conducting other patient surveys or census surveys from 4 weeks prior to and during the period when the PCF PEC Survey is actively surveying. CMS-sponsored surveys such as the CAHPS® for MIPS Survey are exempt from this guidance.
Survey Administration
Why is CMS including a CAHPS/Patient Experience Survey in PCF?
CMS seeks to ensure quality of care, especially the patient experience, is not negatively impacted by PCF's alternative payment model. Patient experience indicates high quality care has been provided according to the patient's own perspective. Positive patient experience is also associated with higher levels of patient adherence, improved clinical outcomes, and lower utilization of inpatient and emergency department services.
Where can I find the PY 2024 survey administration requirements?
The PY 2024 survey administration requirements for the PCF PEC Survey can be found in the Quality Assurance Guidelines.
Where can I find copies of the PY 2024 PCF PEC Survey materials?
All PY 2024 PCF PEC Survey materials, including the mail survey, are posted here on the PCF PEC Survey website for your reference. They are also posted on PCF Connect.
Who can practice sites contact if they have questions about the survey?
Please contact PCF Support via e-mail at PCF@Telligen.com or call 1-888-517-7753. If you have questions related to survey administration, please contact your vendor directly.
When will data collection for the PCF PEC Survey occur?
Data collection occurred in the fall of each performance year. As of March 2025, the CMS Innovation Center announced that the Center is terminating the PCF model one year earlier than originally planned. Therefore, the PCF PEC survey will not be fielded in 2025.
What are the data collection modes for the PCF PEC Survey?
The PCF PEC Survey is an annual survey conducted once per year. It is a single-phase of data collection. Sampled patients received up to 2 mail surveys and 6 telephone calls over the 12-week data collection period.
What language(s) is the survey offered in?
The survey is available in English and Spanish. Sampled patients with a language barrier may still participate in the survey with assistance from a friend or family member, who can translate the survey (mail or telephone) for them. Practice site staff may not act as interpreters or translators.
Why does the survey ask about the past 6 months when the patient rosters ask for a list of patients since January 1st?
To be as inclusive as possible on the patient rosters, CMS asked practices to list all patients with a visit since January each year. This was intended to help CMS obtain a sampling frame of active patients at the practice. The 6-month lookback period is a standard part of the CG CAHPS 3.0/3.1 and CAHPS Patient-Centered Medical Home v. 3.0 questionnaire item sets, and aids in respondent recall.
Are there any restrictions on fielding other surveys at the same time as PCF PEC Survey?
To avoid imposing on patients, CMS strongly encourages practice sites to refrain from conducting other patient surveys or census surveys from 4 weeks prior to and during the period when the PCF PEC Survey is actively surveying. CMS-sponsored surveys such as the CAHPS® Survey for MIPS are exempt from this guidance. When conducting other surveys, practice sites must not ask any additional survey questions that are the same as or similar to those included in the PCF PEC Survey questionnaire. (This guidance does not apply to other CMS-sponsored surveys). Other surveys can include questions that ask for more in-depth information as long as the questions are different from those included in the PCF PEC Survey.
Sampling
Are all practice sites required to submit a patient roster to CMS?
As of March 2025, the CMS Innovation Center announced their decision to end PCF Model participation for both Cohort 1 and Cohort 2 practices a year early on December 31, 2025. As a result of this accelerated timeline, the PEC Survey for PY 2025 was cancelled. There is no additional practice action, such as submitting a patient roster or authorizing a vendor, required for practices.
How many patients were sampled from my practice? How did you decide how many to sample? Is there a minimum response rate?
Each year, CMS draws a random sample of rostered patients. The sample is designed to be representative of all rostered patients, and large enough to yield sufficient completed surveys to achieve an acceptable level of reliability (i.e., ability to find statistically significant differences between practices). CAHPS surveys and surveys that form the basis for payment determinations have widely accepted the coefficient of 0.70 as the threshold for interclass (i.e., between-practice) reliability. The PCF PEC Survey followed recommended guidelines to determine the number of surveys needed to meet or exceed reliability of 0.70, based on practice size. There is no required minimum response rate for Performance-based Adjustment (PBA) scoring, but the survey vendor does send the survey to a large number of patients so that even if the response rate is low each practice can be expected to meet a minimum number of responses. The minimum number of responses is set to satisfy criteria for adequate measure reliability.
PCF always bases scores on the responding patients. Practices' results are then risk-adjusted to remove any patient-level factors outside of the control of practices (for example patient health status, education or age) which may affect scores.
Why did CMS ask practices to provide an all-patient roster for the PEC Survey (not just Medicare beneficiaries)?
We requested your all-patient roster to send a sample of your patients the PEC Survey. Measuring and improving care for all patients is a crucial aspect of PCF. CMS shares the survey results with your practice to help you make changes to improve your patients' experience of care.
Survey Measures and Reporting
Which official CAHPS survey needs to be fielded for Primary Care First?
The PCF PEC Survey is based on a combination of questions from the CG-CAHPS v.3.1 and CAHPS Patient-Centered Medical Home Item Set v. 3.0. A copy of the PY 2024 PEC Survey is posted on the PCF PEC Survey web portal for vendors and practice sites and can be found here.
What kind of questions are asked in the PCF PEC Survey?
The questions in the survey ask about health care experiences. For example, how hard or easy it is to get appointments, and if the patient's health care team listens and explains things in a way that is easy to understand. The survey is posted here on the PEC Survey website.
What if my practice's survey has a low response rate?
PCF PEC Survey protocols are specifically designed to meet target response rates and yield the required number of completed surveys. If a practice does not meet the reliability threshold, CMS will use the responses that were received, and the scores will be calculated based on those responses.
Does CMS publicly report the results of PCF PEC Survey anywhere?
The results of the PCF PEC Survey are not publicly reported. Practice sites receive individual reports with summary data in Q2.
Individual practice results of the PEC Survey are not publicly reported. CMS made additional PCF Model level results publicly available on the CMMI PCF website in winter 2022. These results include PCF region-level average PEC Survey Summary score and region-level average domain performance for Cohort 1 practices. Practice-level data in this report indicates what benchmark decile each practice’s PEC Survey summary score fell within. If you would like more information on how PEC Survey scores are calculated, or benchmark PEC Survey scoring, please reference section 4.1.1.3 Patient Experience of Care Survey Measurement of the Payment and Attribution Methodologies resource.
How will practices receive the results of the PCF PEC Survey?
CMS prepares personalized, easy to understand score reports for each practice site. The report reflects all Complete and Partially Complete surveys for that practice site.