Spring 2022 HOS Newsletter
Volume 11, Issue 1
Welcome to the Spring 2022 edition of the Medicare Health Outcomes Survey (HOS) Newsletter. Previously published in the Winter and Summer, this newsletter will now be published in the Spring and Fall. The new publishing schedule aligns more closely with the latest survey administration schedule and the timing of release of survey results. This newsletter is designed to provide general updates about the HOS Program and is shared with all who request it. The current issue and all previous issues are available on the HOS website.

The newsletter also provides a mechanism to share best practices, research results and other HOS-related material. What information would be helpful for your research, quality improvement, or other endeavors? Let us know and it will be considered for future editions. Medicare Advantage Organizations (MAOs) and other stakeholders are encouraged to send suggestions and ideas to hos@hsag.com.
What's New
Survey Administration and Reporting Schedule Continuing in 2022
  • The 2022 HOS and HOS-Modified (HOS-M) survey administration will follow the same general timeline of the past two years as listed on the Program Timeline page. The first questionnaire mailing begins on July 25, 2022 and the telephone interviewing will end on October 31, 2022.
  • HOS Performance Measurement (PM) data distribution will continue to coincide with the release of the corresponding PM reports in early August, prior to the plan preview periods.
  • The Baseline and HOS-M reports were distributed in the Fall of 2021 and the HOS-M data were made available for distribution at the same time. This distribution schedule for Baseline reports, HOS-M reports, and HOS-M data will continue in 2022.

2022 Display Measures
As described in the HPMS memo released in August 2021, the HOS outcome measures Improving or Maintaining Physical Health and Improving or Maintaining Mental Health were moved to display status by the Centers for Medicare & Medicaid Services (CMS) for the 2022 and 2023 Star Ratings (see the Medicare HOS Survey Administration and Star Ratings Timeline table below). Because the outcomes are designed to measure the ability of MAOs to improve or maintain the health of their enrollees over time, the significant and disparate effects of the COVID-19 Public Health Emergency (PHE) cannot be isolated in the models that predict expected changes in physical health, mental health, and mortality. However, beneficiary-level data collected before and during the pandemic are being provided to contracts for use in quality improvement and to help MA contracts better understand the impact of the pandemic on Medicare beneficiaries physical and mental health. The Physical Functioning Activities of Daily Living (PFADL) also continues as a display measure.

HPMS Release 1 in Early August 2022
The Healthcare Effectiveness Data and Information Set (HEDIS) HOS Effectiveness of Care Report (HEDIS HOS Report), first released in 2021, will continue to be provided in August, at the same time the PM reports are released in HPMS. The report presents results of the HEDIS measures derived from HOS (a.k.a., the “HEDIS Effectiveness of Care” measures) for each MAO based on data from the HOS Round 24 surveys (combined Cohort 24 Baseline and Cohort 22 Follow Up data) collected in 2021. Releasing these two reports together provides MAOs an opportunity to evaluate their HOS Performance Measurement outcome results while considering their HEDIS HOS process measure results. Both reports will be released together in the HPMS Release 1 module for ease of use and comparison. This timing continues to support efforts by MAOs to target health improvement interventions more closely for their beneficiaries.

New SEER-MHOS Data Linkage
The Surveillance, Epidemiology, and End Results-MHOS (SEER-MHOS) data linkage was recently updated on the NCI site and now includes cancer data through 2017, Medicare HOS survey data through 2019, and Medicare Part D claims data through 2019. The linkage also includes data from three newly participating SEER registries.

SEER-MHOS is a linked data set created in collaboration with CMS and the National Cancer Institute (NCI). The SEER-MHOS data set links the SEER cancer registries with responses from MAO enrollees who participated in the HOS. The SEER-MHOS provides detailed clinical, demographic, and cause of death information for Medicare beneficiaries with cancer. Cancer related claims information reported by the participating SEER registries are included in the data. The SEER- More information, including instructions on how to submit a Data Use Application, can be found at: https://healthcaredelivery.cancer.gov/seer-mhos/
HOS Timeline
Each annual round of HOS data collection, data management, and results reporting follows standardized protocols. The annual baseline and follow up surveys are administered together by CMS-approved HOS survey vendors. The fielding phase of the 2022 HOS starts on July 25, 2022, with the telephone follow up finishing on October 31, 2022. After the survey vendors submit final survey data files in November, HSAG evaluates, analyzes, case-mix adjusts, scores, and aggregates the results as described on the Program Timeline page. Baseline and Performance Measurement reports and data sets are then created and delivered to CMS, MAOs, and other data users.

HOS 2022 Administration Cycle
The next session of the annual HOS survey vendor training is planned for May of 2022. To administer the HOS, conditionally approved survey vendors must participate in the annual survey vendor training and successfully complete the post-training evaluation. Survey vendors receive an overview of survey vendor requirements including data submission and coding, quality oversight, and data management. Survey vendor training slides from prior trainings can be found on the Survey Administration page on the HOS website. Additional resources to learn more about the HOS such as technical reports, webinars, and manuals can be found on the Resources page.

Following training, the 2022 lists of CMS-approved HOS and HOS-M Survey Vendors will replace the lists of provisionally approved survey vendors, which are displayed along with other timeline information on the HOS website Program page in the Survey Vendors section. The 2022 HOS and HOS-M Survey Administration memos can be found on the Survey Administration page. Copies of the HEDIS® MY 2021, Volume 6: Specifications for the Medicare Health Outcomes Survey and other Volume 6 manuals may be obtained at no cost on the National Committee for Quality Assurance (NCQA) website (https://store.ncqa.org/hedis-quality-measurement/hedis-specifications-for-the-medicare-health-outcomes-survey.html). A link to download the 2022 HOS Quality Assurance Guidelines and Technical Specifications (QAG) manual will be provided on the Survey Administration page of the HOS website when available.

Star Ratings Timeline
The following table depicts the timeline for HOS data collection, report distribution to MAOs, and Star Ratings year.
Star Ratings - Spring 2022
The highlighted sections of the table above depict the relationship between recent data collection and upcoming reporting periods. The green highlighted sections show how the 2023 Medicare Star Ratings data are from the 2019-2021 Cohort 22 HOS measures and 2021 HEDIS Effectiveness of Care measures that were collected in 2021. The yellow highlighted sections show how the 2022 Medicare Star Ratings data are from the Cohort 21 HOS measures and HEDIS Effectiveness of Care measures that were collected in 2020.

HOS Reports Available
The most recently available HOS reports include:

  • 2018-2020 Cohort 21 HOS Performance Measurement Reports
  • 2020 HEDIS HOS Reports
  • 2020 Cohort 23 HOS Baseline Reports
  • 2020 HOS-M Reports

Registered Health Plan Management System (HPMS) users have access to these reports through the HPMS site. The following CMS site has information about how to establish access to HPMS: www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/HPMS/Overview. If you require assistance accessing reports in HPMS, please contact CMS via email at hpms_access@cms.hhs.gov.

A table on the HOS website Survey Results page provides general survey status information, cohort sample sizes, and response rates for the baseline and follow up surveys that have been administered and reported through 2021. The HOS website also provides downloadable sample HOS-M, HEDIS HOS Effectiveness of Care, Baseline, and Performance Measurement reports with actual aggregate national benchmark data compared to example plan data. These are made available on the Sample Reports page.

HOS and HOS-M Data Sets Available
HOS and HOS-M data sets are available that provide member-level survey responses for each participating MAO and Program of All-Inclusive Care for the Elderly (PACE) organization. Designated data recipients (refer to your HPMS memo for details) may request their data sets. The data sets and accompanying Data Users Guides (DUGs) available by request include:

  • HOS Cohorts 1-21
  • HOS-M 2007-2020

The DUG included with each data set supplies detailed documentation about file construction and contents for the data set. In the DUG you will find information on methodology and design, the survey instrument, data file characteristics, data file layout by position, annotated baseline surveys, and follow up surveys. The first request for a cohort data set is provided without charge to the plan’s designated data recipient. Additional copies may be requested by the designated data recipient of your organization for a fee per data set.

Contact the HOS Team at hos@hsag.com to request data for your MAO or PACE organization. Encrypted data are distributed to designated recipients via secure file transfer.
Medicare Star Ratings Components
Medicare Star Ratings are derived in part from the two functional health outcome measures and three effectiveness of care measures calculated from beneficiary responses to HOS questions. CMS uses these Star Ratings to help consumers compare health plans based on quality and performance and to reward top-performing health plans. The measure scores obtained through the HOS contribute to individual Star Ratings that are created on a five-star rating scale. When combined with other measurement results, these measure scores contribute to the summary-level Part C Star Ratings which are reported on the Medicare Plan Finder page (www.medicare.gov/plan-compare). Consumers can search for health plans in their geographic area and compare costs, coverage, and quality information.

Functional Health (Outcome) Measures
The Functional Health (Outcome) Measures are longitudinal. The plan scores from these measures are calculated from responses to the survey of the same cohort of beneficiaries at the baseline measurement and two years later at the follow up remeasurement.

  • Improving or Maintaining Physical Health
  • Improving or Maintaining Mental Health

As noted earlier in this newsletter, this year’s outcome measures will be displayed for informational purposes only and are not being used for Star Ratings calculation.

Effectiveness of Care (Process) Measures
The Effectiveness of Care (Process) Measures are cross-sectional, and the plan scores are calculated using data collected from a single round. The Effectiveness of Care measures use the data collected in a single survey year for both the baseline cohort and the follow up cohort combined. As noted previously, the HEDIS HOS measure reports have been made available concurrently with the PM reports, beginning in 2021.

  • Monitoring Physical Activity
  • Improving Bladder Control
  • Reducing the Risk of Falling

Current Methodology for Calculating PCS and MCS Results
Scoring the physical component summary (PCS) and mental component summary (MCS) is done in two steps. The first step calculates the unadjusted PCS and MCS scores from the Veterans RAND 12-Item Health Survey (VR-12) questions in the HOS 3.0 questionnaire. The second step calculates the adjusted change scores for the HOS Performance Measurement analysis. Beneficiaries age 65 or older, for whom both baseline and follow up PCS and MCS scores could be computed and who remained in their original MAO, were included in the Respondent sample for PCS and MCS outcomes. Please refer to Appendix 1 of the Sample PM Report (available on the HOS website) in the “Calculating Performance Measurement Results” section, which describes the questions used to calculate PCS and MCS scores, and the case-mix adjusted PM results. The coefficient tables of the covariates used in the case-mix models are also made available on the HOS website Survey Results page. Beneficiary-level actual and expected results are then aggregated and used to derive the MAO-level Improving or Maintaining Physical Health (PCS better or same) and Improving or Maintaining Mental Health (MCS better or same) measures reported in the Medicare Part C Star Ratings.

Further details about the HOS variables are provided in the Performance Measurement DUG available on the HOS website. Reference articles with detailed information about the scoring for the PCS and MCS, a schematic of the items used in the scoring, scoring algorithms, and detailed information about the HOS case-mix adjustment are found on the HOS website Methodology page. An MAO may be able to approximate its expected PCS better or same (without death) and expected MCS better or same results closely using its own PM data file. However, exact replication of the final results may not be possible because records of disenrolled beneficiaries (that contribute to the case-mix adjustment for death) are not available to individual MAOs.
Of Note
Of Note
Researchers continue to use the HOS data for studies examining population health and ways that the health of older adults living in the United States can be improved. Several recent examples are highlighted here. A more comprehensive listing that includes sample HOS reports, foundational research and technical reports, and other research studies can be accessed on the Publications and Resources pages.

Trends in Cardiovascular Disease by Asian American, Native Hawaiian, and Pacific Islander Ethnicity, Medicare Health Outcomes Survey 2011–2015
Cardiovascular disease (CVD), the leading cause of death in the US, poses a unique and multilateral burden for racial and ethnic minorities. The mixture of comorbidities, structural barriers, and psychosocial standing complicates the prevention, diagnosis, and management of CVD in minority populations, and requires new approaches to reduce existing disparities. A recent study that used HOS data, “Trends in Cardiovascular Disease by Asian American, Native Hawaiian, and Pacific Islander Ethnicity, Medicare Health Outcomes Survey 2011–2015,” published in The Journals of Gerontology, examined the increasing risk of CVD in these aging minority populations and can be found here. [1]

The main objective of the study was to examine the prevalence and determinants of CVD risk factors (obesity, diabetes, smoking status, hypertension) and CVD conditions (coronary artery disease [CAD], congestive heart failure [CHF], myocardial infarction [MI], other heart conditions, and stroke) for 10 Asian American and Native Hawaiian/Pacific Islander (NH//PI) subgroups and White adults.

The results of this study showed that among the 639,862 respondents, including 26,853 Asian American and 4,926 NH/PI adults, 13% reported CAD, 7% reported CHF, 10% reported MI, 22% reported other heart conditions, and 7% reported stroke. CVD risk factors varied by Asian American and NH/PI subgroups. Obesity, diabetes, and hypertension were more prevalent in all groups and Native Hawaiians had significantly higher risk of stroke. Based on these findings, future research should disaggregate racial and ethnic data to investigate the development of prevention and treatment strategies to reduce CVD risk in Asian Americans and NH/PIs.

[1] Đoàn LN, Takata Y, Hooker K, et al. Trends in Cardiovascular Disease by Asian American, Native Hawaiian, and Pacific Islander Ethnicity, Medicare Health Outcomes Survey 2011–2015, The Journals of Gerontology: Series A, 2021. Available at: https://doi.org/10.1093/gerona/glab262. Accessed on December 28, 2021.

The impact of hepatocellular carcinoma diagnosis on patients’ health-related quality of life
Patients with hepatocellular cancer (HCC) are known to have worse health-related quality of life (HRQOL) than the general population. However, the change in HRQOL from before diagnosis to after diagnosis remains unknown and difficult to estimate. A recent study that used SEER-MHOS data, “The impact of hepatocellular carcinoma diagnosis on patients' health-related quality of life,” published in Cancer Medicine was released in 2021 and can be found here. [2]

The researchers compared HCC cases with matched controls to evaluate the differences in change in HRQOL before and after HCC diagnosis. The researchers performed a propensity score-matched analysis using the self-reported HRQOL data from the linked 1998-2014 SEER-MHOS data. Cases selected were Medicare beneficiaries (aged ≥65 years) who were diagnosed with HCC between their baseline and follow-up assessments.

The results of the study showed that subjects were more likely to report declines in the mental component of HRQOL after diagnosis of HCC. [2] Based on these findings, the researchers noted that diagnosis of HCC had a profound negative impact on patients’ HRQOL, and their mental health deteriorated significantly over time. Therefore, it is essential to include mental health services within a multidisciplinary HCC care model.

[2] Verma M, Paik JM, Younossi I, et al. “The impact of hepatocellular carcinoma diagnosis on patients' health-related quality of life.” Cancer Medicine vol. 10,18 (2021): 6273-6281. doi:10.1002/cam4.4166. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8446553/. Accessed on January 5, 2022.

Evaluating health-related quality of life as a prognostic tool for overall survival in routine cancer care for older patients with bladder cancer: A US based study
An important treatment goal for many cancer patients is to prolong HRQOL. Due to the severity of symptoms and the toxicity of treatment, HRQOL has especially become a major area of concern when treating elderly patients with cancer. Compared with younger patients, elderly patients with cancer face unique challenges because many of them also experience other age-related declines in health. A research report, “Evaluating health-related quality of life as a prognostic tool for overall survival in routine cancer care for older patients with bladder cancer: A US based study,” was published in Urologic Oncology in 2022. The study, which utilized SEER-MHOS data, and examined the association of longitudinally assessed HRQOL and overall survival (OS) in patients with a history of bladder cancer (BC), can be found here. [3]

This longitudinal retrospective cohort study used the 1998-2013 SEER-MHOS linked data and included patients with HRQOL assessments using the SF-36/VR-12 both pre- and post-BC diagnosis. Within the study cohort of 438 BC patients, the researchers observed that deceased patients (n = 222; 50.7%) were significantly older than those who remained alive (77.2 vs. 75.4 years; P = 0.004). Furthermore, associations between physical component summary and mental component summary (PCS/MCS) scores and OS indicated that elderly BC patients with better physical and mental health were more likely to survive longer. Based on these findings, tracking HRQOL in routine cancer care would promote early detection of HRQOL decline and enable timely intervention by clinicians to improve overall survival.

[3] Pandit AA, Bhandari NR, Khalil MI, et al. “Evaluating Health-Related Quality of Life as a Prognostic Tool for Overall Survival in Routine Cancer Care for Older Patients with Bladder Cancer: A US Based Study.” Urologic Oncology: Seminars and Original Investigations, Elsevier, 26 Oct. 2021, Available at: https://www.sciencedirect.com/science/article/pii/S1078143921004385. Accessed on January 5, 2022.
Frequently Asked Questions
Recent questions received by our Medicare HOS Information and Technical Support site include:

Where can I find the current survey administration documents?
The 2021 survey administration documents are available via the Survey Administration link. The documents include the HOS and HOS-M survey administration memos for MAOs and PACE organizations, and the HOS exclusion memo. Information about HOS program requirements can be found in the HEDIS MY 2020, Volume 6: Specifications for the Medicare Health Outcomes Survey Manual available from NCQA (https://store.ncqa.org/hedis-quality-measurement/hedis-specifications-for-the-medicare-health-outcomes-survey.html) and 2021 Quality Assurance Guidelines and Technical Specifications Manual, Version 2.4, available on the Resources page. Information about HOS survey vendors is available on the Program page in the Survey Vendors section. Survey vendors approved to administer the 2022 HOS survey will be posted during the Spring of 2022.

A November 2021 HPMS memo release has indicated that HOS-M data are available for distribution. My plan participates in the HOS-M, can I still request the data?
The 2020 HOS-M data became available on November 5, 2021. Plans that participated in HOS-M during the 2020 administration are encouraged to request their data. Though the memo went out in November 2021, plans may continue to request available data at their earliest convenience. Data requests should be sent to hos@hsag.com. In your e-mail, please include the plan’s contract number, the name of the data recipient along with their email and phone number, and your plan’s address.

Have the data distribution periods changed for HOS and HOS-M data availability?
Data distribution for HOS and HOS-M occur at distinct time periods in the year. In the past, HOS-M data were available in the summer while HOS Performance Measurement data were available in late fall. Beginning in 2020, the data distribution period of HOS data changed to summer. Meanwhile in 2021, the data distribution of HOS-M data changed to late fall. Based on the current timeline, it is expected that these changes will continue in the future. This means HOS data are slated to be made available in the summer and HOS-M data distribution is expected to occur in late fall. HPMS memos will be sent out on the first day of each of these periods to alert plans of data availability. The tables below provide an outline of the current projected timelines for the respective data distribution periods.
Spring 2022 Data
Where can a PACE organization find the CMS frailty rate that is calculated from the HOS-M?
The HOS-M report distribution occurs electronically to participating plans through HPMS. Two separate HOS-M reports are derived from the annual HOS-M for PACE organizations. CMS Survey Results for Frailty Adjustment can be accessed through the HPMS Risk Adjustment module in the winter following data collection and provide the CMS frailty rate and Activities of Daily Living (ADL) distributions considered for payment purposes. CMS provides the HOS-M Feedback Reports through the Quality and Performance/HOS module one year after the data collection. This report includes summary measures of physical and mental health functioning of the PACE organization’s members.

The definition of a completed survey for the HOS-M Feedback Report is based on the VR-12 summary measures, while a completed survey for the frailty assessment is based on responses to the ADL questions. Therefore, the ADL distributions derived for each report may differ somewhat due to the differing sample selection. Questions about the HOS-M Feedback reports may be directed to the hos@hsag.com mailbox, and questions about the Risk Adjustment reports may be directed to the CMS mailbox at RiskAdjustmentPolicy@cms.hhs.gov.

What are the requirements for oversampling in HOS?
All MAOs required to report HOS will have the option of oversampling in the current survey year for the baseline sample. Oversampling involves surveying a sample of members that is larger than the required sample size of 1,200. There is currently no upper limit on oversampling for HOS; however, this guidance may change in future survey administration years. Oversampling can only occur at the contract level for the Baseline sample. The follow-up sample is still selected based on follow-up members with eligible PCS and MCS scores from two years prior. Oversampling requests should be expressed as a whole number percentage of the sample size. MAOs must notify the HOS Project Team at NCQA (hos@ncqa.org) of oversampling requests by the due date that is specified in the HOS documentation memo, and all oversampling requests are subject to approval by CMS.

Can you clarify what is meant by the “blackout period” for contacting beneficiaries?
Health plans are strongly discouraged from fielding non-CMS surveys to their members eight (8) weeks prior to or during the announced HOS data collection period. This timeframe is sometimes referenced as the “blackout period.” Specific dates for the annual data collection period can be found on the Program page of the HOS website in the Program Timeline section.

What specific topics and activities should plans avoid with beneficiaries during the blackout period?
CMS explicitly prohibits MAOs from implementing practices that could bias or otherwise improperly influence scores. MAOs should also be aware that any internal surveys fielded by the health plan to Medicare beneficiaries during HOS administration could have a negative effect on response rates and scores. Member outreach or communication on a variety of topics that are not specific to HOS-related topics and occur throughout the year is acceptable. However, member outreach that is specific to HOS topics should occur outside of the HOS administration period. Health plans may conduct focus groups with HOS-like questions, assuming the focus groups address broader health topics, are not specific to HOS-related topics, and are conducted throughout the year. A healthcare provider may discuss healthcare concerns with a patient that may relate to HOS survey questions. It is also permitted for a provider to suggest to the patient to recollect that discussion if a patient receives an HOS survey in the future.

I am interested in using HOS data for research purposes. What are my options for data sets, and what approval do I need?
General information about the available HOS data files, variables contained in each file, and requirements for obtaining files may be found on the Research Data Files page of the HOS website. There are three categories of research data files, and they are described in more detail below.

HOS Public Use File (PUF):
  • Baseline and Analytic HOS PUFs, and corresponding PUF DUGs, are available for each cohort of data. The PUFs are constructed in a manner that prevents the identification of any single beneficiary or plan through the removal of identifying fields and aggregation of demographic categories. HOS PUF files are available for download on the HOS website Research Data Files page. Corresponding information about the DUGs may be found on the Data Users Guides page.

Limited Data Set (LDS) File:
  • HOS LDSs, by cohort, comprise all HOS survey items with the exception of direct person and plan identifiers. These data files are available as SAS datasets, and a signed Data Use Agreement (DUA) with CMS is required to obtain an LDS file.
  • Research requests for LDS files must be submitted through the CMS Limited Data Set File Process, and the instructions are available at www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/HOS.

Research Identifiable File (RIF):
  • HOS RIFs comprise all HOS survey items, including the direct person and plan identifiers. Consistent with LDS files, RIFs are available as SAS files, and a signed DUA with CMS is required to obtain a RIF.
  • Requests for HOS RIFs are processed through the Research Data Assistance Center (ResDAC) at the University of Minnesota.

Where can I obtain copies of the HOS and HOS-M surveys?
The HOS and HOS-M survey instruments can be downloaded from the NCQA website (https://www.ncqa.org/hedis/measures/hos/).
Medicare HOS Contacts

General Questions about the Medicare HOS:
Contact Medicare HOS Information and Technical Support
Telephone: 1-888-880-0077
Email: hos@hsag.com.

Questions about the HOS Program or Policy:
Contact the Centers for Medicare & Medicaid Services at hos@cms.hhs.gov.

Medicare HOS website:
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