Health Care Financing Review

Health Outcomes Survey

Measuring and Improving Health Outcomes in Medicare: The Medicare HOS Program
Samuel C. (Chris) Haffer, Ph.D. and Sonya E. Bowen, M.S.W.
(.pdf 352KB)

The Medicare Health Outcomes Survey (HOS) (originally called the Health of Seniors Survey) was developed as a longitudinal performance measure to assess the physical functioning and mental well being of Medicare beneficiaries over time. The survey was implemented nationally in Medicare managed care organizations (MCOs) as part of Medicare HEDIS®‚ 3.0/1998 and continues today. In 1998, a pilot test of the HOS in Medicare FFS was conducted; the pilot test concluded in 2001. This overview discusses the importance of functional status assessment, reviews the goals of the HOS, and explains how researchers and quality improvement professionals are using the data to explore functional status measurement issues, describe policy and programmatic implications for CMS, and identify opportunities to improve health care practice.

Psychometric Evaluation of the SF-36® Health Survey in Medicare Managed Care
Barbara Gandek, M.S., Samuel J. Sinclair, M.Ed., Mark Kosinski, M.A., and John E. Ware, Jr., Ph.D.
(.pdf 436KB)

Data quality and scoring assumptions for the SF-36® Health Survey were evaluated among the elderly and disabled, using 1998 Cohort I baseline Medicare HOS data (n=177,714). Missing data rates were low, and scoring assumptions were met. Internal consistency reliability was 0.83 to 0.93 for the eight scales and 0.94 and 0.89, respectively, for the physical (PCS) and mental (MCS) component summary measures. Results declined with increased risk factors (e.g., older age, more chronic conditions), but were well above accepted standards for all subgroups. These findings support using standard algorithms for scoring the SF-36® in the HOS and subgroup analyses of HOS data.

Estimation of Non-Response Bias in the Medicare FFS HOS
Nancy McCall, Sc.D., Galina Khatutsky, M.S., Kevin Smith, M.A., and Gregory C. Pope, M.S.
(.pdf 383KB)

We examined non-response bias in physical component summary scores (PCS) and mental component summary scores (MCS) in the Medicare fee-for-service (FFS) Health Outcomes Survey (HOS) using two alternative methods, response propensity weighting and imputation for non-respondents. The two approaches gave nearly identical estimates of non-response bias. PCS scores were 0.74 points lower and MCS scores 0.51 points lower after adjustment for non-response through imputation and 0.63 and 0.46 lower after adjustment for propensity weighting. These levels are small for component scores suggesting that survey non-response to the FFS HOS does not adversely affect estimates of average health status for this population.

Measurement Comparisons of the Medical Outcomes Study and Veterans SF-36® Health Survey
Lewis E. Kazis, Sc.D., Austin Lee, Ph.D., Avron Spiro, III, Ph.D., William Rogers, Ph.D., Xinhua S. Ren, Ph.D., Donald R. Miller, Sc.D., Alfredo Selim, M.D., M.P.H., Alaa Hamed, M.P.H., and Samuel C. (Chris) Haffer, Ph.D..
(.pdf 427KB)

The Medicare Health Outcomes Survey (HOS) uses the Medical Outcomes Study (MOS) SF-36® among beneficiaries enrolled in Medicare managed care programs, whereas the Department of Veterans Affairs (VA), Veterans Health Administration (VHA) has administered the Veterans version of the SF- 36® for quality management purposes. The Veterans version is comparable to the MOS version for 6 of the 8 scales, but distinctly different in role physical (RP) and role emotional (RE) scales. The gains in precision for the Veterans SF-36® provide evidence for the use of this version in future applications for assessing patient outcomes across health care systems.

Health Status of Dually Eligible Beneficiaries in Managed Care Plans
Terry R. Lied, Ph.D. and Samuel C. (Chris) Haffer, Ph.D.
(.pdf 425KB)

We conducted a descriptive study examining the health status of dually eligible beneficiaries using a sample from the Medicare Health Outcomes Survey (HOS), a measure of health status administered to enrollees in Medicare managed care (MMC). Overall, we found that dually eligible beneficiaries were sicker, more depressed, and reporting more pain than Medicare-only beneficiaries. Our results suggest that quality improvement initiatives that center on pain and depression management in the dually eligible population present important opportunities for collaboration between Medicare and Medicaid.

Chronic Conditions: Results of the Medicare Health Outcomes Survey, 1998-2000
Beth Hartman Ellis, Ph.D., Erin Dowd Shannon, M.P.H., Jacquilyn Kay Cox, Ph.D., Leona Aiken, Ph.D., and Brenda M. Fowler, M.S.
(.pdf 427KB)

This research examines the predictors of 2- year declines in physical and mental health for beneficiaries surveyed in the Medicare Health Outcomes Survey (HOS). Regression results indicate that age, arthritis of the hip/knee, sciatica, and pulmonary diseases, comorbidity at baseline, and increased comorbidity between baseline and followup were predictors of decline in physical health; however, these account for very small amounts of variance. The number of newly diagnosed chronic conditions and depression predicted decline in mental health. Beneficiaries deceased at followup were of lower socioeconomic status, and had lower physical and mental health scores than the analytic sample.

Use of HOS Data in Florida
Kathie McDonald, R.N., M.P.H., C.I.C., Jifeng Ma, Ph.D., and Elaine Dulabone, R.N.
(.pdf 427KB)

The Medicare Health Outcomes Survey (HOS) is a longitudinal cohort study that assesses physical and mental functioning of Medicare enrollees in MCPs. Realizing the potential of HOS data to improve health care, the Florida Medicare Quality Improvement Organization (QIO) analyzed HOS scores and shared them with M+COs to assist in evaluating the efficacy of their disease management programs. The QIO also discusses additional uses for HOS data such as cross-linking with a patient satisfaction survey and sharing with health care organizations that collaborate with the QIO.

HOS Highlights:

High rates of comorbidity present a challenge in providing care to elderly Medicare managed care enrollees. Comorbidity or the presence of coexisting illness strongly influences utilization, costs, and outcomes of health care. Ischemic heart disease (IHD) and congestive heart failure (CHF) are leading causes of morbidity and mortality among Medicare beneficiaries. Both have been the targets of successful quality improvement initiatives by CMS (Jencks, Huff, and Cuerdon, 2003). Medicare HEDIS® has targeted improved management of hypertension and diabetes, as well as smoking cessation, all important risk factors for IHD and CHF. The impact of disease management programs on outcomes for these conditions is being evaluated in CMS demonstration projects (Haffer et al., 2003). Additional improvements in quality and outcomes of care for beneficiaries with these conditions may be achieved by improving management of common coexisting illnesses.

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This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees. We explain the model's principles, elements, organization, calibration, and performance. Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondarypayer subpopulations are discussed.

DataView

National health expenditures (NHE) were $1.6 trillion in 2002, a 9.3-percent increase from 2001. For the fourth consecutive year health spending grew faster than the overall economy as measured by the GDP. Growth in U.S. health care spending rose for most health services in 2002, with hospital spending once again the primary driver.

Statements contained in Review articles and abstracts are solely those of the authors and do not express any official opinion or endorsement by the Centers for Medicare and Medicaid Services (CMS).