Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Plan Survey (HP CAHPS), Version 5.1

The HP CAHPS Survey measures key components of patient experience, such as how well doctors communicate and getting needed care, that are consistent with patient-centered care. The CAHPS Surveys focus on aspects of care that consumers have identified as important and for which patients are the best or only source of information. Measuring patients’ perceptions of their healthcare experience is not just a means to improve services—it’s a recognition that the patient’s voice matters in and of itself. Listening to patients affirms their role as active participants in their care, and their insights are essential to truly understanding the quality and impact of healthcare delivery. In 2024, over 200,000 health plan enrollees throughout the country completed the HP CAHPS Survey for their health plan and their health plan submitted this data to the AHRQ CAHPS Database. Since submission to the AHRQ CAHPS Database is not mandatory, it is likely that far more health plans are administering and using these data. Public reporting of these survey results creates incentives for health plans and state agencies to improve their quality of care, directly impacting the patients who receive it. Because of this, it is important to ensure that the survey aligns with what patients believe constitutes high-quality care. We reviewed the literature on the determinants of patient care experiences measured by CAHPS and their associations with other indicators of health care quality. CAHPS is also an actionable measure that helps health plans target interventions that will improve the quality and patient-centeredness of care.

Review of the Evidence

Prior research has identified several features of healthcare delivery structure, including plan characteristics and market-level characteristics that are associated with patient experiences.  Three major systematic reviews have examined the relationships among patient experience, clinical processes, and patient outcomes. A systematic review performed by researchers in the U.K. found that patient experience is favorably associated with adherence to recommended medications and treatments, preventive care such as screenings and immunizations, patient-reported health outcomes, clinical outcomes, reduced hospitalizations and primary care visits, and reduced adverse events (Doyle et al., 2013). Anhang Price et al. (2014) reviewed evidence on the association between patient experiences and other measures of health care quality in the U.S. They similarly found that better patient care experiences are associated with higher levels of adherence to recommended prevention and treatment processes, better clinical outcomes, and less health care utilization. Navarro et al. (2021) reviewed 9 studies and found that ratings of patient experience is related to the overall rating of health care and can influence clinical and quality outcomes.

Structure

Health plan type and market characteristics have been found to predict patient experience in several studies. Among managed care organizations (MCOs), for example, Medicaid enrollees had significantly less favorable CAHPS scores than commercial plan enrollees (Elliott, Farley, et al., 2005). For-profit and nationally affiliated health plans tended to receive worse patient experience scores, particularly on overall ratings of the health plan and composite measures on health plan customer service and access (Landon et al., 2021). The financial strength of health plans, as measured by their fiscal margins, was associated with more favorable CAHPS scores (Beauvais et al., 2007). Market-level factors such as HMO competition and penetration did not appear to affect patient experience (Scanlon, Swaminathan, et al., 2008), but Medicare beneficiaries in “higher-intensity” healthcare markets reported more problems getting care quickly than in markets with less healthcare consumption (Mittler, Landon, et al., 2010). For health plans, prior work highlights multi-level impacts on patient experience, which can occur at the system, care site, or physician level – with physicians accounting for the largest proportion of explainable variance (Rodriguez, Scoggins, at al., 2009). Improving the infrastructure supporting certain aspects of care may have broad effects because system changes can influence multiple outcomes (Cleary, 2016).

Quality Improvement / Interventions

Researchers have used the CAHPS survey to learn if accountable care organization (ACO) incentives to limit health care use and improve quality may enhance or hurt patients’ experiences with care. More specifically, using CAHPS survey data covering 3 years before and 1 year after the start of Medicare ACO contracts in 2012 as well as linked Medicare claims, McWilliams et al. (2014) compared patients’ experiences in a group of 32,334 fee-for-service beneficiaries attributed to ACOs (ACO group) with those in a group of 251,593 beneficiaries attributed to other providers (control group), before and after the start of ACO contracts. They found that, in the first year, ACO contracts were associated with meaningful improvements in some measures of patients’ experience and with unchanged performance in others. Lastly, studies have found that hospitals with more positive perceptions of patient safety culture tend to have more positive CAHPS scores from their patients (Sorra et al., 2012; Abrahamson et al., 2016). This finding suggests that improvements in patient safety culture may lead to improved patient experience with care.

Outcomes

Out of 40 evidence papers with outcome measures, Doyle’s (2013) meta- analysis found 29 studies that reported positive associations between patient experience and clinical outcomes, 11 with no associations, and none with negative associations. The lack of more evidence may be due to associations between a patient’s illness level, their level of care, and their likelihood for a poor outcome such as mortality, morbidity, or a readmission. Often, such associations have more than one plausible direction of causality. For example, clinicians may be especially attentive to the needs of sicker patients (Kahn et al., 2007) and patients near the end of life (Elliott, Haviland, et al., 2013). 

Moreover, substantial evidence points to a positive association between various components of patient experience, such as good communication between clinicians and patients, and several important processes and outcomes. These include lower utilization of unnecessary healthcare services; better patient adherence to medical advice; better process of care measures for acute myocardial infarction (AMI), congestive heart failure, pneumonia and surgery; lower inpatient mortality among acute myocardial infarction (AMI) patients; lower infection rates (Anhang Price et al., 2014); and better clinician and staff perceptions of patient safety culture (Sorra et al., 2012). 

Schneider and colleagues (2001) found that two HP CAHPS Survey composites were associated with several Healthcare Effectiveness Data and Information Set (HEDIS) clinical process measures among Medicare health plan enrollees. They found that experiences obtaining needed care and getting information and customer service from health plans were associated with mammography, eye examinations for diabetics, receipt of beta-blockers following myocardial infarction, LDL cholesterol testing following an acute cardiovascular event, and follow-up within 30 days following a hospitalization for mental illness (Schneider et al., 2001).

Utilization

Research suggests an association between better patient experiences and lower healthcare utilization. Platonova and Carnes (2023) found that better results on the measure Provider Communication composite measure led to 19% fewer ER visits for Medicaid patients in North Carolina. The items within the composite measure had strong relationships with ER visits, with provider treating the patient with respect associated with 37% fewer ER visits. 

In another study, children with asthma were less likely to visit the emergency department, make urgent office visits, or be hospitalized if their physicians had reviewed a long-term therapeutic plan with their parents (Clark, Cabana, et al., 2008).  Among African Americans with Type 2 diabetes, those who reported that doctors or nurses usually listened carefully or spent enough time with them were significantly less likely to visit the emergency department in the 12 months following completion of a patient experience survey (Gary, Maiese, et al., 2005). Fenton et al. found that patients who rated their providers most highly had lower odds of visiting the emergency department but higher odds of being admitted to the hospital the following year (Fenton, Jerant, et al., 2012). Children whose parents report longer waits for primary care visits were more likely to visit the emergency department for non-urgent reasons than those who report waiting for less time (Brousseau, Bergholte, et al., 2004).

Health-related Patient Behavior and Disease Management

One composite of the HP CAHPS survey assesses patients’ perceptions of how well providers communicate with them.  Better patient-provider communication promotes healthcare-related patient behaviors (Fuertes, Boylan, et al., 2009). A 2009 meta-analysis of 127 studies assessing the link between patient treatment adherence and physician-patient communication found a 19% higher risk of non-adherence among patients whose physician communicated poorly (Zolnierek and Dimatteo, 2009). Doyle’s (2013) meta-analysis showed positive associations between the quality of clinician-patient communications and adherence to medical treatment in 125 of 127 studies analyzed. Studies using the CAHPS measure have found that better provider communication is positively associated with adherence to hypoglycemic medications among diabetics (Ratanawongsa, Karter, et al., 2013), adherence to tamoxifen among breast cancer patients (Liu, Malin, et al., 2013), and higher rates of colorectal cancer screening among adults in the US (Carcaise-Edinboro and Bradley, 2008).

References

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Anhang Price, R, Elliott, MN, Zaslavsky, AM, Hays, RD, Lehrman, WG, Rybowski, L, Edgman-Levitan, S, Cleary, PD. (2014) Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 71(5), 522-54.

Beauvais, B, Wells, R., Vasey, J., and DelliFraine, J. (2007). Does money really matter? The effects of fiscal margin on quality of care in military treatment facilities. Hosp. Top. 85(3), 2-15.

Brousseau, D. C., Bergholte, J.,et al. (2004). The effect of prior interactions with a primary care provider on nonurgent pediatric emergency department use. Archives of Pediatrics & Adolescent Medicine. 158(1), 78-82.

Carcaise-Edinboro, P. and Bradley. CJ. (2008). Influence of patient-provider communication on colorectal cancer screening. Medical Care. 46(7), 738-745.

Clark, NM., Cabana, MD. et al. (2008). The clinician-patient partnership paradigm: Outcomes associated with physician communication behavior. Clinical Pediatrics. 47(1), 49-57.

Cleary, PD. (2016) Evolving concepts of patient-centered care and the assessment of patient care experiences; optimism and opposition. J Health Pol, Policy & Law. 41(4), 675-696.

Doyle, C., L. Lennox, et al. (2013). A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open. 3(1). http://bmjopen.bmj.com/content/3/1/e001570.full

Elliott, MN., Farley, D., Hambarsoomians, K., and Hays, R.D. (2005). Do Medicaid and commercial CAHPS scores correlate within plans?: A New Jersey case study. Med Care. 43(10), 1027-1033.

Elliott, MN., Haviland, AM., et al. (2013). Care experiences of managed care Medicare enrollees near the end of life. Journal of the American Geriatrics Society 61(3), 407-412.

Fenton, JJ., Jerant, AF., et al. (2012). The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Archives of Internal Medicine. 172(5), 405-411.

Fuertes, JN., Boylan, LS., et al. (2009). Behavioral indices in medical care outcome: The working alliance, adherence, and related factors. Journal of General Internal Medicine. 24(1), 80-85.

Gary, TL., Maiese, EM., et al. (2005). Patient satisfaction, preventive services, and emergency room use among African-Americans with type 2 diabetes. Disease Management. 8(6), 361-371.

Kahn, KL., Tisnado, DM., et al.  (2007).  Does ambulatory process of care predict health-related quality of life outcomes? Health Services Research. 42, 63-83.

Landon, BE., Zaslavsky, AM., Beaulieu, ND., Shaul, JA., Cleary, PD. (2021). Health plan characteristics and consumers’ assessments of quality. Health Affairs, 20(2). 274-286.

Liu, Y., Malin, JL., et al. (2013). Adherence to adjuvant hormone therapy in low-income women with breast cancer: The role of provider-patient communication. Breast Cancer Research and Treatment. 137(3), 829-836.

McWilliams, JM, Landon, BE, Chernew, ME, Zaslavsky, AM. (2014). Changes in patients' experiences in Medicare Accountable Care Organizations. N Engl J Med. 371(18), 1715-24.

Mittler, J., Landon, B., Fisher, E., Cleary, P., and Zaslavsky, A. (2010). Market variations in intensity of Medicare service use and beneficiary experiences with care. Health Serv Res 45(3), 647-669.

Navarro, S., Ochoa, CY., Chan, E., Du, S., Farias, AJ. (2021). Will improvements in patient experience with care impact clinical and quality of care outcomes?: A systematic review. Medical Care. 59(9), 843-856, DOI: 10.1097/MLR.0000000000001598

Platonova, EA, Carnes, KJ. (2023). Relationship between patient-centered primary care provider communication and emergency room visits in the Medicaid population in North Carolina, United States. J Prim Care Community Health. 14, doi: 10.1177/21501319231171430

Ratanawongsa, N., Karter, AJ., et al. (2013). Communication and medication refill adherence: the Diabetes Study of Northern California. JAMA Internal Medicine. 173(3), 210-218.

Rodriguez, HP, Scoggins, JF, von Glahn, T, Zaslavsky, AM, Safran, DG. (2009) Attributing sources of variation in patients' experiences of ambulatory care. Med Care. 47(8), 835-41.

Scanlon, D., Swaminathan, S., Lee, W., and Chernew, M. (2008). Does competition improve health care quality? Health Serv Res. 43(6), 1931-1951.

Schneider, EC, Zaslavsky, AM, et al. (2001). National quality monitoring of Medicare health plans: the relationship between enrollees' reports and the quality of clinical care. Medical Care. 39(12), 1313-1325.

Sorra, J, Khanna, K, Dyer, N, Mardon, R, Famolaro, T. (2012) Exploring relationships between patient safety culture and patients’ assessments of hospital care. Journal of Patient Safety 8(3), 131–139.

Zolnierek, KB. and Dimatteo, MR. (2009). Physician communication and patient adherence to treatment: a meta-analysis. Medical care. 47(8), 826-834.