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Medicare Health Outcomes Survey

Medicare Health Outcomes Survey Overview

Introduction to Medicare HOS

CMS is committed to monitoring the quality of care provided by M+COs. To better evaluate this care, CMS, in collaboration with the National Committee for Quality Assurance (NCQA), launched the first Medicare managed care outcomes measure in the Health Plan Employer Data and Information Set (HEDIS®) in 1998. The measure includes the most recent advances in summarizing physical and mental health outcomes results and appropriate risk adjustment techniques. This measure was initially titled Health of Seniors, and was renamed the Medicare Health Outcomes Survey during the first year of implementation. This name change was intended to reflect the inclusion of people with Medicare who are disabled and under age 65 in the sampling methodology.

The HOS measure was developed under the guidance of a Technical Expert Panel (TEP) comprised of individuals with specific expertise in the health care industry and outcomes measurement. The TEP continues to provide input for developing the science of the HOS measure. CMS has contracted with NCQA to support the standardized administration of the HOS survey, including selecting, training, and certifying independent survey vendors that the plans contract with to administer the survey.

Data collection for Cohort I Baseline (Round One) occurred in 1998, and findings were distributed in 1999. Data collection for Cohort II Baseline (Round Two) occurred in 1999, and findings were distributed in 2000. Data collection for Cohort III Baseline and Cohort I Follow Up (Round Three) occurred in 2000, and findings were distributed in 2001. Data collection for Cohort IV Baseline and Cohort II Follow Up (Round Four) occurred in 2001, and findings were distributed in 2002. Data collection for Cohort V Baseline and Cohort III Follow Up (Round Five) occurred in 2002, and findings were distributed in 2003. Data collection for Cohort VI Baseline and Cohort IV Follow Up (Round Six) occurred in 2003, and findings were distributed in 2004. Most recently in 2004, data collection for Cohort VII Baseline and Cohort V Follow Up (Round Seven) occurred, and findings will be distributed in 2005.


Development of the Medicare HOS

In the mid-1990s, Medicare beneficiaries were joining health maintenance organizations (HMOs) and other types of managed care organizations (MCOs) in increasing numbers. It became apparent to CMS that the Agency needed performance reporting requirements for Medicare managed care. CMS worked with NCQA to incorporate the Medicare population into NCQA's HEDIS® performance measurement set. HEDIS® was rapidly becoming a standard reporting requirement of purchasers in the commercial insurance market.

The integration of the Medicare population into HEDIS® was achieved with the release of HEDIS® 3.0. CMS, NCQA and others felt there was a need to develop additional measures for the Medicare population including an "outcomes" measure for HEDIS®. Traditionally, HEDIS® contained "process" measures that assessed interventions such as mammograms for older women and retinal eye exams for people with diabetes. While evidence in the scientific literature tied the measured processes or interventions to favorable patient outcomes, there was a desire to develop an outcomes measure that captured performance across multiple aspects of care.

CMS, NCQA, Health Assessment Lab (HAL), and performance measurement experts worked together to develop a measure that would assess the physical functioning and mental well being of Medicare beneficiaries over time. It was decided that this measure should include a set of survey questions known as the SF-36®. The SF-36® was developed as part of the Medical Outcomes Study, a national research effort, and has a long history of use in estimating relative disease burden for numerous conditions. The survey is referenced in the literature in connection with over 150 diseases and conditions including arthritis, back pain, depression, diabetes and hypertension. Additional items were included in HOS in addition to the SF-36® survey to allow for case mix adjustment, which is essential for meaningful and valid plan-to-plan comparisons of health outcomes.

The HOS measure was approved for inclusion in HEDIS® 3.0 by the Committee on Performance Measurement (CPM), the NCQA panel that oversees the development and evolution of HEDIS®. CMS has contracted with Health Assessment Lab, the Health Outcomes Technologies Program (HOT) at the Boston University School of Public Health, Health Services Advisory Group (HSAG), National Committee for Quality Assurance, QualityMetric (QM), and the Research Triangle Institute (RTI) International's Division of Health Economics Research (DHER) to implement and operationalize all aspects of the HOS measure. For additional information on the HOS project team, please refer to the HOS Partners section.


Medicare HOS Timeline

HOS survey data are collected annually for a new sample of members (cohort), with a two year follow up for each baseline cohort.

Medicare HOS Timeline
  ROUND
ONE
(1998)
ROUND
TWO
(1999)
ROUND
THREE
(2000)
ROUND
FOUR
(2001)
ROUND
FIVE
(2002)
ROUND
SIX
(2003)
ROUND
SEVEN
(2004)

COHORT I
(CI)
 
CI
Baseline
Data
Collection
CI
Baseline
Report
CI
Follow Up
Data
Collection
CI
PM Report
     

COHORT II
(CII)
 
  CII
Baseline
Data
Collection
CII
Baseline
Report
CII
Follow Up
Data
Collection
CII
PM Report
   

COHORT III
(CIII)
 
    CIII
Baseline
Data
Collection
CIII
Baseline
Report
CIII
Follow Up
Data
Collection
CIII
PM Report
 

COHORT IV
(CIV)
 
      CIV
Baseline
Data
Collection
CIV
Baseline
Report
CIV
Follow Up
Data
Collection
CIV
PM Report

COHORT V
(CV)
 
        CV
Baseline
Data
Collection
CV
Baseline
Report
CV
Follow Up
Data
Collection

COHORT VI
(CVI)
 
 
 
 
 
 
CVI
Baseline
Data
Collection  
CVI
Baseline
Report

COHORT VII
(CVII)
 
 
 
 
 
 
  CVII
Baseline
Data
Collection


PM = Performance Measurement


Reporting Medicare HOS Results

The Medicare HOS results are used to monitor the health of the general population, to evaluate treatment outcomes and procedures, and to provide external performance measurement. Baseline and performance measurement results are disseminated in cohort specific reports to participating M+COs and QIOs at the conclusion of each reporting cycle.

The Medicare HOS Baseline reports are produced and disseminated after each baseline cohort's data are collected and analyzed. Please be advised that the baseline report is not suitable for plan-to-plan comparisons.

The Medicare HOS Performance Measurement Report is produced and disseminated after the collection of two-year follow up data on each cohort. Performance Measurement results reflect a health plan's ability to maintain or improve the physical and mental health functioning of its Medicare beneficiaries over a two-year period of time. The goal of the HOS Performance Measurement Report is to promote quality improvement. It is part of a larger effort by CMS to improve the health care industry's capacity to sustain and improve health status and functioning within the senior population.

For detailed information on Medicare HOS Reporting, please refer to the Medicare HOS Results section.


Medicare HOS Instrument

The Medicare HOS instrument consists of three components: the SF-36® Health Survey; questions for case mix and risk adjustment purposes; and questions added by CMS as required by the 1997 Balanced Budget Act. Physical and mental functioning are measured with the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, which are derived from the SF-36®.

The following Medicare HOS Survey Instruments are available for download:

SF-36 Health Survey

The SF-36® is a multi-purpose, short-form health survey with only 36 questions. It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. As documented in more than 2,500 publications, the SF-36® has proven useful in both general and specific populations, comparing the relative burden of diseases, differentiating the health benefits produced by a wide range of different treatments, and screening individual patients.

The SF-36® asks respondents about their usual activities and how they would rate their health. It is a barometer of physical and mental health functional status. It yields an 8-scale profile of scores as well as physical and mental health summary measures. Concepts (8 scales) included in the SF-36® are:

  • Physical Functioning (PF) - These ten questions ask respondents to indicate the extent to which their health limits them in performing physical activities.
  • Role-Physical (RP) - These four questions assess whether respondents' physical health limits them in the kind of work or other usual activities they perform, both in terms of time and performance.
  • Role-Emotional (RE) - These three questions assess whether emotional problems have caused respondents to accomplish less in their work or other usual activities, both in terms of time and performance.
  • Bodily Pain (BP) - These two questions determine the respondents' frequency of pain and the extent to which it interferes with their normal activities.
  • Social Functioning (SF) - These two questions ask respondents to indicate limitations in social function due specifically to health.
  • Mental Health (MH) - These five questions ask respondents how frequently they experience feelings representing four major mental health dimensions: anxiety, depression, loss of behavioral/emotional control and psychological well being.
  • Vitality (VT) - These four questions ask respondents to rate their well being by indicating how frequently they experience energy and fatigue.
  • General Health (GH) - These five questions ask respondents to rate their current health status overall, susceptibility to illness, and their expectations for health in the future.

The eight scales form two distinct higher-ordered clusters (principal components) that are the basis for scoring the physical (PCS) and mental (MCS) component summary measures. These components account for 80-85% of the reliable variance in the eight scales in the US general population and in other countries, in both cross-sectional and longitudinal studies. This discovery made it possible to reduce the number of statistical comparisons involved in analyzing the SF-36® (from eight to two) without substantial loss of information.

PCS scores are a reliable and valid measure of physical health. Very high PCS scores indicate no physical limitations, disabilities, or decline in well being; high energy level; and a rating of health as excellent. Very low PCS scores indicate limitations in self care, physical, social and role activities; severe bodily pain; frequent tiredness; and a rating of health as poor.

MCS scores are a reliable and valid measure of mental health. Very high MCS scores indicate frequent positive affect, absence of psychological distress, and no limitation in usual social and role activities due to emotional problems. Low MCS scores indicate frequent psychological distress, and social and role disability due to emotional problems.


Continue on to the HOS Results section.



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