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.

What are the practice responsibilities for the PEC Survey?

Please see this document, Practice Site Responsibilities for PCF PEC Survey.

Where can I find the list of approved survey vendors?

You can find the list of Approved Survey Vendors here.

When will the approved PCF PEC Survey vendor list be released?

The PCF PEC Survey Vendor Solicitation occurs in January of each Performance Year. The updated vendor list is published in May and can be found here.

How do I register for login credentials on the PEC Survey Website?

Please see this Quick Link, How to Register for Practice Login Credentials.

How do I register a practice site?

Please see this Quick Link, How to Register a Practice Site.

How do I register additional Cohort 2 practices to my account?

Cohort 1 practice site administrators who wish to register additional Cohort 2 practices can do so by selecting "Practice Site ID Registration" from the Practice Sites tab of the PCF PEC Survey Website. You can check to see which practice sites have already been registered to your account by viewing the Registered Practice Site ID Report also located under the Practice Sites tab.

How do I authorize a survey vendor?

Please see this Quick Link, How to Authorize a Survey Vendor.

How do I change a vendor authorization?

Please see this Quick Link, How to Switch Survey Vendors.

Does our practice need to authorize a vendor every year?

Once authorization is submitted, it remains valid for the duration of the model, unless the practice site terminates the authorization.

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. We encourage practices to contact vendors for cost and service information as there may be differences among vendors. The list of CMS-approved survey vendors for the PCF PEC Survey is here.

We already have a BAA with a survey vendor. Can we use that?

Please discuss questions about Business Associate Agreements and contracts with your selected survey vendor. Your BAA must refer to Primary Care First, must include the relevant (current) performance years for PCF and should include all participating practice sites.

Our practice already conducts a patient survey. Can PCF use those data instead?

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. PCF practices are 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.

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 Accountable Care Organizations Participating in Medicare Initiatives are exempt from this guidance.

For more information, please reference the resource Responsibilities of Primary Care First (PCF) Practice Sites for the Patient Experience of Care Survey.

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 will also be 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. Please see the Practice Site Responsibilities for the PCF PEC Survey for more information.

Will new PEC Survey vendors be added to the list in the future?

New PEC survey vendors may be added each year of PCF. Survey vendors interested in becoming a CMS-approved PCF PEC Survey vendor must meet the PCF PEC Survey Minimum Business Requirements, which include minimum 3 years' experience conducting CAHPS surveys for CMS and a minimum 3 years' experience conducting mixed-mode (mail and telephone) surveys. Survey vendors will be invited to apply in January each year; eligible interested vendors may also contact pcfpecs@rti.org. An updated list of survey vendors will be published every May. Practices should wait until the list is updated in May to authorize a vendor if they would like to see the final list of fully approved vendors.

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 survey administration requirements?

The survey administration requirements for the PCF PEC Survey can be found in the Quality Assurance Guidelines.

Where can I find copies of the PCF PEC Survey materials?

All 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.

My patient has questions, who should they call?

Patients should call the Help Desk using the contact information provided by your survey vendor. This contact information can be found on the questionnaire cover letter, the postcard, the poster, and the waiting room FAQs.

What should we tell our patients about the survey?

Please see the section "Communicate with patients about the survey in accordance with CMS specifications" in this document, Responsibilities of PCF Practice Sites for the Patient Experience of Care Survey (PEC Survey).

How long does the survey take?

The PCF PEC Survey takes about 20 minutes.

When will data collection for the PCF PEC Survey occur?

Data collection occurs in the fall of each performance year.

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 will receive 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. Vendors and practice sites are not permitted to translate the survey into other languages; only CMS-provided translations are permitted. CMS may provide other translations in upcoming years of PCF. Practice sites should inform their vendor of additional translation needs so that they may be shared with CMS. 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.

Please see the Introduction to the PCF PEC Survey webinar for additional information about the PEC Survey.

Why does the survey ask about the past 6 months when the patient rosters ask for a list of patients since January 1^st?

To be as inclusive as possible on the patient rosters, CMS asks practices to list all patients with a visit since January. This is 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.

Can the practice get another poster/another copy of the patient FAQs?

Yes, please go to PCF Connect to download a high-resolution copy of the poster/copy of the patient FAQs to print.

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?

Yes, each PCF practice is required to submit an individual patient roster to CMS for the PEC Survey/CAHPS, even if the practice is part of a larger health care organization with multiple practices participating in PCF.

Why is CMS requesting a roster of our practice site's patients and how will the data be used?

Complete and accurate patient roster information is very important to the success of the PEC Survey and helps maximize response rates. The PEC Survey is administered using mail data collection with a telephone follow-up. This type of patient sampling makes obtaining accurate patient addresses and telephone numbers especially critical in the rostering process. The address information practices provide within the patient roster is used for first attempts in getting your patients to complete the survey. The telephone numbers provided in the patient roster are also important, as this is how nonrespondents are contacted in the last few weeks of data collection. Accurate telephone numbers help practices get feedback from hard-to-reach populations.

When will the roster information be available?

Roster instructions, templates, and on-demand webinar are available to practice sites and health IT vendors via Connect. Any updates to the materials are shared with health IT vendors no later than three months prior to roster submission and with practices no later than one month prior to roster submission. Practices receive communication about these materials and deadlines via First Edition and Connect.

How do I upload a patient roster?

Practices received the PCF Patient Roster Instructions and Frequently Asked Questions (FAQs) and PCF Patient Survey Roster Template via the First Edition newsletter in April. These materials were posted on PCF Connect. A recorded webinar, PCF Patient Rosters: How to Support a Successful PEC Survey For Your Practice, was also made available to practices via Connect and is updated annually in April. Practices will not submit patient rosters on the PCF PEC Survey website. Rosters will be submitted on the PCF Portal. Practices should contact PCF Support at PCF@Telligen.com or (888) 517-7753 with any questions.

How are patients chosen to receive a PCF PEC Survey? Will all patients receive a survey?

CMS will select a random sample of patients from the rosters submitted by practices. Not all patients will receive a survey. The sample will consist of the following patient specifications:

• All payers, self-pay, or no insurance
• Ages 18 and above
• All patients who had at least one visit during the visit window. The visit window begins on January 1 of the Performance Year and ends whenever the practice site submits their roster.
  • If the patient had any visit in the window, in-person or telehealth, they are eligible.

Practices should exclude as ineligible:

• patients who are deceased, who reside in nursing homes/skilled nursing facilities, who only visited your practice site for a COVID test or vaccine, and patients whose addresses are outside the US.

People who live in residential care/assisted living facilities are eligible.

More details about the specifications for inclusion in the patient rosters/sample can be found in the Patient Roster Instructions and Frequently Asked Questions, on PCF Connect and in the PCF Portal. Practices may also refer to Chapter 4 of the Vendor Quality Assurance Guidelines, posted on the PCF PEC Survey website.

How many patients will you sample from my practice? How do 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 follows 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 is CMS asking practices to provide an all-patient roster for the PEC Survey (not just Medicare beneficiaries)?

We are requesting 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 will share 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 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.

Can practices add their own questions to the PCF PEC Survey?

Yes, practices can add practice-specific questions as long as they abide by the requirements in the Quality Assurance Guidelines Section 5.5.6.

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.