CMS Releases HCAHPS National Pandemic Performance Data

Nurse talking to patient in wheelchair during COVID-19 Pandemic

In CMS’s recent publish of the proposed rule in the Federal Register, they anticipate not using any calendar year 2020 HCAHPS data in VBP—either for the performance period for FFY2022 or as the baseline for FFY2024. (Previously, they had exempted the optionally submitted quarters of Q1 2020 and Q2 2020 from inclusion in VBP.)

This rule included a comparison of individual hospitals’ scores to try to isolate the influence of the pandemic on HCAHPS scores. They compared mode and patient mix adjusted top box scores for hospitals that had at least 25 completed surveys each quarter (to yield an annual N of at least 100 surveys). By looking at the same quarters, they also accounted for seasonal fluctuations in the data.

If you review the changes in scores for the pre-pandemic quarters, you’ll see that generally, hospitals improve quarter to quarter, although those improvements are always less than one percentage point of a top-box score.

During the first two quarters of the pandemic, many hospitals opted to skip data submission, but among those who did submit, we see that changes in scores compared to the same quarter in 2019 tended to be larger and negative—including changes in scores for Nurses, Responsiveness, Communication about Medicines, and Care Transition that were more than one point lower than in 2019.

Changes in HCAHPS Top-Box Points Chart

*Significant at p<0.05; **Significant p<0.005; ***Significant at p<0.0001
Table from the IPPS FY2022 Proposed Rule, FR 2021-08888, page 25473, publication date 05/10/2021
Shaded cells had changes of greater than one top-box point.

Note that the Q3 comparisons on the far right are the most generalizable as hospitals could not opt out of submission during that quarter, and we hope to see Q4 comparisons provided by CMS in the final rule. We encourage you to review the discussion in the proposed rule starting on page 25472 (or page 403 of the pdf), “Proposal to Suppress the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Measure (NQF #0166) for the FY 2022 Hospital VBP Program Year” and consider these observed effects when evaluating your own performance during the pandemic.