Spring 2023 HOS Newsletter
Volume 12, Issue 1
Welcome to the Spring 2023 edition of the Medicare Health Outcomes Survey (HOS) Newsletter. Published each year in the Spring and Fall, the newsletter aligns with the survey administration schedule and the distribution of survey results to Medicare Advantage Organizations (MAOs). 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, recent 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. MAOs and other stakeholders are encouraged to send newsletter suggestions and ideas to hos@hsag.com.
What's New
Using the HOS for Quality Improvement and Population Health
One of the major goals of the HOS is to disseminate results that can be used by MAOs to inform quality improvement activities that improve the health of all their enrollees. While health care is provided to individuals, HOS results are reported at the contract level and represent the self-reported health outcomes of the MAO’s MA population.

The Baseline HOS is not designed to report individual outcomes or patient level results to MAOs, but rather to encourage MAO accountability at the contract level. Beneficiary level data are made available to contracts only after Follow-Up data collection and Performance Measurement reporting are completed.
  • This timing (both Baseline and Performance Measurement) encourages MAOs to apply interventions across their entire enrollee population, rather than targeting those who may have been sampled for HOS participation.
  • MAOs are encouraged to use their aggregated Baseline HOS results to identify contract priorities and their two-year Follow-Up HOS results to track progress and improvement at the contract level. MAOs should use clinical data to screen for and address needs at the patient level.

Although the HOS is a longitudinal survey, contract-level aggregate and comparative survey results are securely distributed to MAOs each year.
  • For example, HOS Cohort 24 Baseline and Cohort 22 Follow-Up were fielded in 2021. Contract-level Cohort 22 Performance Measurement results were available to the MAOs in July 2022 and contract-level Cohort 24 Baseline Reports were available in October 2022.

It is important to recognize that MAOs conduct internal quality improvement activities to support the health of all enrollees, and intervene when health improvement opportunities are identified in individuals. A comprehensive quality improvement approach goes beyond using beneficiary-level HOS data to address concerns among specific enrollees and instead uses the information to devise approaches that improve health outcomes for all members.
  • For example, if the Baseline HOS results indicate a high percentage of contract enrollees report sleep disturbances, MAOs can use this information to support screening and quality improvement efforts that address sleep for all enrollees. The successes of those efforts are then evident by the results reported at Follow Up.

2023 and 2024 Display Measures
Three HOS outcome measures, Improving or Maintaining Physical Health; Improving or Maintaining Mental Health; and Physical Functioning Activities of Daily Living, remain on display status for the 2023 and 2024 Star Ratings (see the Medicare HOS Survey Administration and Star Ratings Timeline table below).

Health Plan Management System (HPMS) Release 1 in Early August 2023
The Healthcare Effectiveness Data and Information Set (HEDIS) HOS Effectiveness of Care Report (HEDIS HOS Report) will be released concurrently with the HOS Performance Measurement (PM) reports to eligible MAOs in HPMS. The HEDIS HOS Report presents results of the HEDIS Effectiveness of Care measures for each MAO based on data from the HOS Round 25 surveys (combined Cohort 25 Baseline and Cohort 23 Follow Up data) collected in 2022. Releasing the HEDIS HOS and PM reports together provides MAOs an opportunity to evaluate their HOS Performance Measurement outcome measure results while considering their HEDIS HOS process measure results. Both reports are supplied together in the HPMS Release 1 module for ease of comparison. This timing continues to support efforts by MAOs to target health improvement interventions for all MA enrollees.
HOS Timeline
Each annual round of HOS data collection, data management, and results reporting follows standardized protocols. CMS-approved survey vendors administer the baseline and follow up surveys concurrently under oversight from the National Committee for Quality Assurance (NCQA). This year’s fielding phase of the HOS starts on July 24, 2023, with the telephone follow up finishing on November 1, 2023. After receiving the final survey data files, HSAG evaluates, analyzes, applies case-mix adjustment, 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 2023 Administration Cycle
The next session of the annual HOS survey vendor update training is planned for May 23, 2023. 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 will be posted after the 2023 training and 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 lists of CMS-approved HOS and HOS-M Survey Vendors for 2023 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 2023 HOS and HOS-M Survey Administration memos can be found on the Survey Administration page. Copies of the HEDIS® MY 2022, Volume 6: Specifications for the Medicare Health Outcomes Survey and Volume 6 manuals for prior measurement years may be obtained at no cost from the NCQA website (https://store.ncqa.org/hedis-quality-measurement/hedis-specifications-for-the-medicare-health-outcomes-survey.html). A link to download the 2023 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.
HOS - Spring 2023
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 derived from the 2019-2021 Cohort 22 HOS measures and HEDIS Effectiveness of Care measures that were collected in 2021. The yellow highlighted sections show how the 2024 Medicare Star Ratings data will be derived from the 2020-2022 Cohort 23 HOS measures and HEDIS Effectiveness of Care measures that were collected in 2022.

HOS Reports Available
The contract-level HOS reports most recently available in HPMS include:
  • 2019-2021 Cohort 22 HOS Performance Measurement Reports
  • 2021 HEDIS HOS Reports
  • 2021 Cohort 24 HOS Baseline Reports
  • 2021 HOS-M Reports

Registered HPMS users have access to these reports through the HPMS site. Information about how to establish access to HPMS is available at: 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.

General survey status information, including fielding dates, sample sizes, and response rates for the baseline and follow up surveys from 1998 to 2022 are available on the HOS website Survey Results page. Downloadable samples of the HOS-M, HEDIS HOS Effectiveness of Care, Baseline, and Performance Measurement reports are available on the Sample Reports page of the HOS website. All sample reports include actual aggregate national benchmark data compared to example plan data.

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 MAO and PACE 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 1-22
  • HOS-M 2007-2021

The DUG included with each data set supplies detailed documentation about file construction and data contents. 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 HEDIS effectiveness of care measures calculated from MA enrollees’ 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 Star Ratings elements 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 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 listed below are longitudinal. The plan scores from these measures are calculated from responses to the survey of the same cohort of MA enrollees at the baseline measurement and two years later at the follow up remeasurement.

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

Both HOS outcome measures remain on display status for 2023 and 2024. Display measures are publicly available for informational purposes but are not used for Star Ratings calculations. Another longitudinal (outcome) measure, Physical Functioning Activities of Daily Living (PFADL), is currently in development and has been on display since 2021.

Effectiveness of Care (Process) Measures
The Effectiveness of Care (Process) Measures listed below are cross-sectional. The plan scores are calculated using the data collected in a single survey year for the combined baseline cohort and the follow up cohort. As noted previously, the HEDIS HOS reports are made available concurrently with the PM reports.

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

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. MA enrollees aged 65 years 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. MA enrollee-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) outcome measures.

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.

Functional Limitations and Physical Health in Community-Dwelling Medicare Advantage Beneficiaries: Variation by Race and Hispanic Subgroup
In a study recently published in the Journal of Aging and Health, researchers reported on variations in the functional health of older adults among people of different races and ethnicities.[1] Using the PCS score and the need for assistance with ADLs self-reported by respondents to the HOS, investigators compared six non-Hispanic groups and five Hispanic subgroups. Cuban and White respondents had the highest PCS scores and the lowest rates of difficulty with ADLs. Even with regression model adjustment for sociodemographic and health characteristics, the researchers found that respondents from multiple other Hispanic groups (as well as Native Hawaiian or other Pacific Islanders) had the highest rates of difficulties with ADLs. Key conclusions from this study were that there is racial and ethnic heterogeneity in physical functioning and that understanding subgroup differences is important when considering strategies for quality improvement.

[1] Luck J, Govier D, Doan LN, Mahakalanda S, Zhang W, Mendez-Luck C. Functional Limitations and Physical Health in Community-Dwelling Medicare Advantage Beneficiaries: Variation by Race and Hispanic Subgroup. J Aging Health. 2022 Dec;34(9-10):1269-1280. doi: 10.1177/08982643221113133. Epub 2022 Sep 29. PMID: 36175065.

Racial/Ethnic Variations in Social Determinants of Mental Health Among Medicare Advantage Beneficiaries.
In this research report, investigators used data from HOS respondents to examine associations between social determinants of health and mental health and how they varied among people of various racial and ethnic groups.[2] Specifically, they looked at respondents’ self-reported number of unhealthy days due to mental health. The researchers found that social and economic factors had stronger associations for Whites, Asians, and multiracial people. They found that those factors were not significant for American Indians/Alaska Natives and Native Hawaiians/Other Pacific Islanders. As with the other study, these researchers noted that the associations varied among the racial and ethnic groups, indicating that homogenous interventions may not be effective for all.

[2] Kim T, White K, DuGoff E. Racial/Ethnic Variations in Social Determinants of Mental Health Among Medicare Advantage Beneficiaries. J Appl Gerontol. 2022 Mar;41(3):690-698. doi: 10.1177/07334648211039311. PMID: 34404243.

Correlates of Health-Related Quality of Life in a National Sample of Older Adult, Long-Term Survivors of Colorectal Cancer
The Surveillance Epidemiology and End Results-Medicare Health Outcomes Survey (SEER-MHOS) data set links patient-reported quality of life outcomes from the HOS with the SEER registry cancer treatment information over extended time periods. This unique data set has allowed researchers to examine possible adverse effects and decreased health-related quality of life (HRQOL) in long-term survivors of colon cancer.[3] Burrell et al found that respondents (with an average time from diagnosis of 13 years) reported that pain, depression, and fatigue were significantly affected in older adults with colorectal cancer. The largest observed contributors to physical and mental HRQOL were the symptoms people experienced, accounting for nearly half of the variance. The researchers recommended aggressive symptom assessment and management in this group of long-term survivors.

[3] Burrell SA, Sasso GE, Greenle MM. Correlates of Health-Related Quality of Life in a National Sample of Older Adult, Long-Term Survivors of Colorectal Cancer. Cancer Nurs. 2023 Jan 20. doi: 10.1097/NCC.0000000000001207. Epub ahead of print. PMID: 36727897.
Frequently Asked Questions
Current topics answered by our Medicare HOS Information and Technical Support include:

Where can I find the current HOS and HOS-M survey vendor lists and survey administration documents?
The most current information for the HOS and HOS-M survey vendor lists is available under the HOS Survey Vendors and HOS-M Survey Vendors sections on the Program page. Survey administration documents, including the 2023 HOS and HOS-M survey administration memos for MAOs and PACE plans, and the HOS exclusion memo, are available under the Survey Administration section. Additional information about HOS program requirements may be found in the HOS Quality Assurance Guidelines (QAG) and HOS-M QAG Addendum, both of which are available in the Methodology section of the Resources page.

What is oversampling in the HOS, and how can I submit a request to oversample?
Oversampling is surveying a sample of members that is larger than the required sample size of 1,200. In any survey year, any MAO that is required to report HOS will have the opportunity to voluntarily request an oversample. Oversampling is at the contract level for the baseline sample and should be expressed as a whole number percentage of the sample size. The follow-up sample is still selected based on the follow-up members with eligible Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from two years prior. MAOs must notify the HOS Project Team at NCQA (hos@ncqa.org) of oversampling requests by the due date that is specified in the current Survey Administration Plan Memo on the Survey Administration page. All oversampling requests are subject to approval by CMS.

Can you clarify what is meant by the “blackout period” for contacting MA enrollees?
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 will be found on the Program page of the HOS website in the Program Timeline section.

What specific topics and activities should plans avoid with MA enrollees 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 members 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.

What types of data sets are available to researchers?
Three basic types of data sets are available to researchers: Public Use Files (PUFs), Limited Data Sets (LDSs) and Research Identifiable Files (RIFs). The PUFs have been constructed so that all the member identifying information contained in the corresponding RIFs (including the name, address fields, Medicare Beneficiary Identifier [MBI] and/or Medicare Health Insurance Claim [HIC] number, where available) have been removed. In addition, plan identifiers have been removed and some demographic fields such as race and age are aggregated to prevent identification of any individuals.

There are two types of PUFs: Baseline and Analytic.

  • Analytic PUFs contain a completed cohort of data for all baseline respondents and are constructed to be self-contained with a baseline and follow up component for each member’s record. There is no field that allows identification of a particular individual across the cohorts in the analytic PUFs.
  • Baseline PUFs have been constructed with a unique anonymous ID field that does allow identification of the same individual across multiple baseline cohorts.

LDSs and RIFs are comprised of the entire national sample for a given cohort (including both respondents and non-respondents), and contain all of the HOS survey items, as well as the physical and mental health summary scores (PCS and MCS). They also contain protected member-level health information such as date of birth, gender, race/ethnicity, and county of residence. However, there are differences between the two types of data sets. For example, the specific direct person identifiers (i.e., name, address, MBI and/or HIC number, where available) are included in the RIFs and allow identification of the same individual across multiple cohorts; however, these identifiers are excluded in the LDSs. Note that the plan identifiers and plan characteristics that are included in the RIFs are blinded, modified, or excluded in the LDSs to prevent identification of specific MAO contracts.

For additional details, see the Research Data Files section of the website. Researchers are encouraged to request information and technical support at HOS@hsag.com for assistance with understanding the data and potential considerations for data requests and analyses.
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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