Established Child Health Care Quality Measures—CAHPS
- Expanded CAHPS 3.0 Child Survey
- Children with Chronic Conditions
- Comparisons and Trends
- Benchmarking and Databases
- Service Delivery and Units of Analysis
- Length-of-Enrollment Requirements
- Data Issues
- Small Numbers
- Resource and Burden Issues
- Development Process
- Criteria Used
- More Information and User Support
CAHPS, formerly known as the Consumer Assessment of Health Plans, is a research-based survey measurement tool that is widely used for assessing access, communication, and other aspects of the experience of health care. The child questionnaires (Child Commercial and Child Medicaid) are administered to parents or guardians. There are several sets of supplemental questions on selected topics, including children with chronic conditions.
CAHPS includes a reporting format developed and tested to ensure effective communication of CAHPS results to target consumer audiences and specifications for proper administration of the survey.
CAHPS was developed by AHRQ under cooperative agreements and contracts with Harvard University, RAND, Research Triangle Institute, and Westat.
In 2002, AHRQ awarded 5-year cooperative agreements to a new group of organizations charged with the continued evolution of CAHPS products. This new consortium includes Harvard Medical School, RAND, American Institutes for Research (AIR), and Westat.
Expanded CAHPS 3.0 Child Survey
The expanded CAHPS 3.0 Child Survey, which permits identification of children with special health care needs (or chronic care conditions), was developed by a collaboration of the Child and Adolescent Health Measurement Initiative (CAHMI), the CAHPS research team, and AHRQ staff.
As a registered member of the CAHPS family of measures, the CAHPS 3.0 Child Survey uses the CAHPS® methodology and scoring protocols. The CAHPS 3.0 Child Survey combines three components:
- The widely used basic CAHPS child core questionnaire, including items that are combined to report five composite measures of:
- How well doctors communicate.
- Getting care quickly.
- Getting needed care.
- Courtesy and helpfulness of office staff.
- Customer service.
- A children with chronic conditions (CCC) set that includes:
- A five-item screener that identifies children with chronic care conditions.
- A set of 31 supplemental questions regarding the health care experiences of children with chronic conditions.
- The CAHPS 3.0 Child Survey, including optional questions applicable to all children in the following areas:
- Communication with providers.
- Interpreter services.
- Dental care.
- Mental health care.
- Claims processing.
- Medicaid enrollment.
- Coverage by multiple plans.
- Well-child care.
Online Resource: For more information on CAHPS optional questions, go to: http://www.ahrq.gov/cahps/index.html.
An additional set of supplemental items entitled "HEDIS" (Health Plan Employer Data and Information Set) is specific to managed care organizations (MCOs). These items are required only when CAHPS results are submitted to the National Committee for Quality Assurance (NCQA) as a part of HEDIS.
Online Resource: CAHPS specifications describe where and how CAHPS supplemental questions can be added without biasing the survey results. If users wish to add their own questions, they should be sure to consult with the CAHPS Survey Users staff. Go to: http://www.ahrq.gov/cahps/index.html.
The task of assessing the quality of health care services for children with chronic conditions is complicated by the "small numbers problem." Compared to adults, children have a larger number of chronic conditions, with relatively few children experiencing each one. In any given health plan or program, attempts to identify children with a single chronic condition typically result in very small numbers of children. For statistical reasons, information on the quality of the health care services received by a small number of children cannot be reliably assumed to describe services received by any other children.
The importance of measuring the quality of services delivered to children with chronic conditions led to the development of a new assessment approach. Under this new noncategorical approach, screener questions are used to identify children with characteristics typical of chronic conditions.
If the screener questions identify at least 100 children with chronic conditions in a given health plan or program, this provides a large enough number to allow analysis of the responses to supplemental questions related to their care. The analysis provides information on how well the plan or program is serving those children and their families.
1. Newacheck PW, Strickland B, Shonkoff JP, et al. An epidemiologic profile of children with special health care needs. Pediatrics 1998;102(1 Pt 1):117-23.
2. Stein RE, Silver EJ. Operationalizing a conceptually based noncategorical definition: a first look at U.S. children with chronic conditions. Arch Pediatric Adolesc Medicine 1999;153(1):68-74.
The CAHPS 3.0 Child Survey CCC Screener identifies children meeting the following three criteria:
- The child currently experiences a consequence associated with a condition.
- The consequence results from a medical, behavioral, or other health condition.
- The duration or expected duration of the condition is at least 12 months.
A child who meets all three criteria qualifies as having a chronic condition.
The screener consists of five main questions, each of which has three parts corresponding to the above criteria. The questions ask about the following five health consequences:
- Use of or need for prescription medicines.
- Above average use of or need for medical, mental health, or educational services.
- Functional limitations compared with others of the same age.
- Use of or need for specialized therapies (e.g., occupational therapy, physical therapy, speech therapy).
- Treatment or counseling for emotional, behavioral, or developmental problems.
Online Resource: Information about the development, reliability, and validity of the screener can be found in the article, "Identifying Children with Special Health Care Needs: Development and Evaluation of a Short Screening Instrument."
Download the article in PDF format (82 KB). Go to: http://www.ahrq.gov/chtoolbx/bethellscreener.pdf.
CCC Supplemental Questions
The CAHPS 3.0 Child Survey includes 31 supplemental questions focusing on topics with special relevance to children with chronic conditions. Topics include the following:
- Access to prescription medicines.
- Access to specialized services.
- Access to family-centered care, including:
- Having a personal doctor or nurse who knows the child.
- Shared decisionmaking.
- Getting needed information.
- Coordination of care and services.
The response sets for the supplemental questions are consistent with the core items in the questionnaire.
Protocols for administering the CAHPS 3.0 Child Survey and analyzing responses are described in the CAHPS Survey and Reporting Kit, available through the CAHPS Survey User Network. Questionnaires, supplemental questions, and sample reporting formats are included as well. Information is also available from the CAHPS Helpline toll free at 1-800-492-9261 or via email at: CAHPS1@ahrq.gov.
Online Resource: To obtain the CAHPS® Survey and Reporting Kit, go to: http://www.ahrq.gov/cahps/surveys-guidance/cg/index.html
The CAHPS 3.0 Child Survey is available in:
CAHPS is widely used by State Medicaid agencies to assess their contracted MCOs. It is also used by some commercial plans. The CAHPS Child Survey Sponsor Profiles present examples of how seven States used the CAHPS Child Survey and contact information for finding out more about these projects.
Comparisons and Trends
The CAHPS 3.0 Child Survey was tested for reliability and validity and was field tested with a variety of consumer groups. CAHPS specifications are described in the CAHPS Survey and Reporting Kit, which is available free of charge. CAHPS results will be reliable and valid if these specifications are followed. They cover:
- Sampling protocols.
- Survey administration protocols.
- Data analysis procedures.
- Reporting procedures.
The results can be used for statistically significant comparisons with CAHPS results produced for other plans or programs and can be used for trending over time, provided that the same or comparable populations are being surveyed. CAHPS results based on properly chosen samples of sufficient size can be generalized to the relevant universe.
Auditing of results to ensure consistent application of specifications and procedures helps ensure comparability of results. NCQA requires auditing of CAHPS results submitted as part of the HEDIS measurement set for MCO accreditation purposes.
Benchmarking and Databases
The National CAHPS Benchmarking Database (NCBD) Chart Books contain CAHPS results from multiple users. States or other CAHPS users interested in comparing their CAHPS results with other results can submit their results to the NCBD and will receive benchmarked results free of charge. All users of CAHPS surveys that are administered independently according to CAHPS specifications are invited to participate. NCBD includes:
- CAHPS response results.
- Information on survey administration (mode of administration, response rate, etc.).
- Descriptive information on health plans.
Service Delivery and Units of Analysis
The CAHPS 3.0 Child Survey targets children 17 years of age and younger who are served by the following types of programs:
- Managed care organizations.
- Fee-for-service (FFS) plans.
- Primary-care case management (PCCM) programs.
The CAHPS 3.0 Child Survey can be used for statewide assessment or for regional or local surveys. Increasing numbers of States are using CAHPS to compare the reported performance of the MCO, FFS, and PCCM components of their Medicaid programs.
Online resource: Information on seven States using the CAHPS Child Survey can be found in the CAHPS Child Survey Sponsor Profiles.
Medicaid managed care beneficiaries must be enrolled at least 6 months, with a break of no more than 30 days, to be part of a CAHPS survey. Commercial (employer-based) plan members must be enrolled at least 12 months, with a break of no more than 45 days. Those using CAHPS with a PCCM or FFS program have generally applied the same enrollment requirements.
The enrollment requirement is designed to ensure that the enrollee has been in the MCO or health plan long enough to provide a basis for holding the plan accountable. The differences in requirements between Medicaid and commercial enrollees reflect the shorter length of enrollment more typical of Medicaid.
CAHPS 3.0 is a survey and reporting tool. It can be administered by:
- Mixed mode, a combination of both. (NOTE: To maximize response rates, administration by mail with telephone followup is recommended.)
- NCQA also allows the use of the Internet to complete CAHPS® 3.0H.
The CAHPS Survey and Reporting Kit discusses the issues involved in alternative modes of survey administration and sample selection. Additional requirements for administering CAHPS 3.0H for submission to NCQA are found in NCQA's HEDIS Vol. 3.
Online Resource: For information about obtaining all HEDIS® volumes, go to: http://www.ncqa.org/hedis-quality-measurement
Data completeness and accuracy are critical issues, whatever the data sources or modes of administration. With survey data, the keys to usable results are:
- The right sample size.
- The right selection methods.
- Adequate response rates.
CAHPS technical specifications require a sample large enough to yield 300 completed questionnaires. Larger sample sizes may be required to get valid information on children with chronic conditions. The CAHPS Survey and Reporting Kit proposes several sampling alternatives for the Child Survey.
Online Resource: You can also consult the Survey Users Network for help with sample size questions. Go to: https://www.ahrq.gov/cahps/index.html
If used for HEDIS reporting, the sample size must yield 411 completed questionnaires. At least 100 responses for children with chronic conditions are required to analyze the CCC supplemental questions. These and related issues are discussed in the CAHPS Survey and Reporting Kit.
Resource and Burden Issues
The production of performance measures is a data-driven activity. Credible survey data require close attention to proper sampling methods and adherence to survey administration protocols. These take time and money. Senior-level agency responsibility and sufficient staff resources are needed to ensure useful results.
The CAHPS survey instrument development process included:
- An AHRQ-funded research consortium composed of Harvard Medical School, RAND, the Research Triangle Institute, and Westat.
- Extensive review of the literature.
- Development and standardization of questions and questionnaires.
- Testing for reliability and validity.
- Cognitive testing to ensure that consumers understand questions and response options as developers intended.
- Tests to assess potential bias resulting from differing modes of survey administration.
- Extensive field testing with multiple and diverse consumer groups.
CAHPS® 1.0 was revised and improved to create CAHPS 2.0. The expanded CAHPS 3.0 Child Survey, including the CCC screener and CCC supplemental questions, resulted from the work of the CAHMI, the CAHPS research team, and AHRQ staff.
Criteria used in developing CAHPS® included:
- Ease of use, relevance, and utility to consumer audiences who have differing reading skills, learning styles, knowledge levels, and interests and needs.
- Focus on assessments of health care experiences for which consumers are the best or only source of information.
- Intention to educate as well as inform.
- Translation into other languages without introducing bias.
- Flexibility, relatively low cost, and ease of production.
More information on the development of CAHPS® is available in the CAHPS® Survey Reporting Kit, or you may wish to read:
Consumer Assessment of Health Plans (CAHPS). Med Care 1999 Mar;37(3 Suppl):MS1-9. No abstract available on PubMed.
For more information and user support, contact the CAHPS® Helpline toll free at 1-800-492-9261 or E-mail firstname.lastname@example.org.
Online Resource: For additional information on the CAHPS® Survey Users Network, go to: http://www.ahrq.gov/cahps/index.html