Publications

Attachment 2
Medicare Health Outcomes Survey Publications
The Medicare HOS Partners and other leading health outcomes experts are involved in research
utilizing Medicare HOS data. These efforts have resulted in the publication of a number of
manuals, peer-reviewed articles, and technical reports. Research based on the HOS data has
been published in academic peer-reviewed journals such as International Journal of Geriatric
Psychiatry, Health Services Research, Health and Quality of Life Outcomes, International
Journal for Quality in Health Care, Health Care Financing Review, and Cancer. Topics such as
depression, smoking, health disparities, and chronic illness have been investigated utilizing HOS
data.
The following list of publications (manuals, peer-reviewed articles, and technical reports) has
been assembled to provide additional information on the Medicare HOS and to facilitate the
utilization of the HOS data files produced by the Medicare HOS Project. The publications are
organized into the following categories: (1) Overview, (2) Methodology, (3) Results, and (4)
Applications/Interventions.

Overview
Peer Reviewed Articles
Haffer, Samuel C. and Bowen, Sonya E. "Measuring and Improving Health Outcomes in
Medicare: The Medicare HOS Program." Health Care Financing Review. Summer 2004.
Volume 25(4): 1-3.
Jones, Nathaniel, III, Jones, Stephanie L. and Miller, Nancy A. "The Medicare Health Outcomes
Survey program: Overview, context, and near-term prospects." Health and Quality of Life
Outcomes. July 12, 2004. Volume 2(33).
Cooper, James K., Kohlmann, Thomas, Michael, James, Haffer, Samuel C. and Stevic, Marcia.
"Health Outcomes. New Quality Measure for Medicare." International Journal for Quality in
Health Care. February 2001. Volume 13(1): 9-16.
Golden, William. "Counterpoint: Integrating Health Status into the Quality Equation."
International Journal for Quality in Health Care. February 2001. Volume 13(1): 5-6.
Safran, Dana G. "Counterpoint: Measuring, Monitoring and Reporting Functional Health
Outcomes: Opportunities and Challenges in a Bold National Initiative." International Journal for
Quality in Health Care. February 2001. Volume 13(1): 7-8.
Haffer, Samuel C., Cooper, James K. and Gordon, Catherine. "The Health of Seniors Project."
Managed Care and Aging. American Society on Aging. Volume 5(2).

Technical Reports
2008 HOS-M Sample PACE Report and 2008 HOS-M Sample SNP Report
The Medicare Health Outcomes Survey-Modified (HOS-M) is an abbreviated version of the
Medicare HOS that is administered to Special Needs Plans (SNPs) and Program of All-Inclusive
Care for the Elderly (PACE) Organizations. The HOS-M report presents physical component
summary scores and mental health summary scores, Activity of Daily Living (ADL) items, and
selected health status measures, for the frail, elderly Medicare beneficiaries for each organization
compared to the entire HOS-M sample.
The Medicare Health Outcomes Survey Evaluation Final Report
In 2003 and 2004, CMS funded an independent evaluation of the HOS program. The evaluation
encompassed three components: 1) a review of the context for the HOS program; 2) an
evaluation of the HOS instrument and operational protocol; and 3) an assessment of policy issues
related to turning HOS data into useful information for health plans, QIOs, CMS and health care
researchers. This final report summarizes the findings of the overall evaluation. A brief overview
is provided on the measurement of quality of care and, in particular, the transition from structural
and process measures of care to outcomes of care. Also discussed is the role of quality of care
assessment and improvement within a broader strategy of health plan performance measurement.
Several national initiatives are noted. Further, factors that contributed to the development of the
HOS program are reviewed, followed by a discussion of the HOS program administration and
data utilization.
Sample Baseline Report
After the administration of each baseline cohort, a cohort specific baseline report is produced.
The baseline reports present physical component summary and mental component summary
scores. The scores are case mix adjusted using demographics, chronic medical conditions, and
HOS study design variables. The baseline reports also provide plan, state, and HOS national
information on the Centers for Disease Control (CDC) Healthy Days measure, the HEDIS
Management of Urinary Incontinence (UI) in Older Adults measure, additional health status
indicators, and demographics.
Sample Performance Measurement Report
After the administration of each follow up cohort, a cohort specific performance measurement
report is produced. A performance measurement report data set is created by merging a cohort's
baseline and follow up data. Additionally, death information is incorporated into the performance
measurement data set for those baseline respondents who died between baseline and follow up.
The HOS performance measurement results are computed using a rigorous case mix/risk
adjustment model. Plans are rated on whether they performed Better than Expected, Same as
Expected, or Worse than Expected on Physical and Mental Health. The performance
measurement reports also provide plan, state, and HOS national information on health status
indicators and demographics.
Implementing the HEDIS® Medicare Health Outcomes Survey: Imputation Analysis for
HOS Income Data. Data from the Medicare Health Outcomes Survey (HOS) offer important
longitudinal information about insights into the self-assessed health status of the older population

in the United States. CMS has surveyed this population annually over several years and
repeatedly found that income information is missing in Baseline and Follow-up surveys for about
10-20 percent of respondents. To address this issue and to generate complete information across
HOS data sets, CMS is collaborating with NCQA to explore and help define a valid income
imputation method using HOS 2000 Cohort 3 Baseline and HOS 2006 Cohort 9 Baseline data
that could be applied to other HOS cohorts.

Methodology
Manuals
National Committee for Quality Assurance (NCQA). HEDIS®, Volume 6: Specifications for
the Medicare Health Outcomes Survey. Washington DC: NCQA Publication, 1998 - 2005.
NCQA annually publishes the HEDIS®, Volume 6: Specifications for the Medicare Health
Outcomes Survey manual. The manual contains background information about the survey, the
measure description, the HEDIS® protocol, the English and Spanish versions of the HOS
questionnaires, and the text for the survey letters and postcards. In addition, the appendix
contains a description of how longitudinal health outcomes are analyzed in HOS and a list of
available HOS resource materials. Copies of HEDIS® Volume 6 may be purchased by calling
NCQA Customer Support at (888) 275-7585 or via NCQA's Secure Online Order Center
(www.ncqa.org).
Peer Reviewed Articles
Hope, MaryAnne DePesquo and Shannon, Erin Dowd "A Comparison of Two Procedures to Fit
Multi-Level Data: PROC GLM versus PROC MIXED." SUGI 30 Proceedings. April 2005.
Gandek, Barbara, Sinclair, Samuel J., Kosinski, Mark and Ware, John E. "Psychometric
Evaluation of the SF-36® Health Survey in Medicare Managed Care." Health Care Financing
Review. Summer 2004. Volume 25(4): 5-25.
McCall, Nancy, Khatutsky, Galina, Smith, Kevin and Pope, Gregory C. "Estimation of NonResponse Bias in the Medicare FFS HOS." Health Care Financing Review. Summer 2004.
Volume 25(4): 27-41.
Kazis, Lewis E., Lee, Austin, Spiro, Avron, Rogers, William, Ren, Xinhua S., Miller, Donald R.,
Selim, Alfredo, Hamed, Alaa and Haffer, Samuel C. "Measurement Comparisons of the Medical
Outcomes Study and Veterans SF-36® Health Survey." Health Care Financing Review. Summer
2004. Volume 25(4): 43-58.
Haffer, Samuel C. "Using Multiple Survey Vendors to Collect Health Outcomes Information:
How Accurate Are the Data?" Health and Quality of Life Outcomes. April 16, 2003. Volume
1(6).

Hwang, Yi-Ting, Bierman, Arlene S., Haffer, Samuel C. and Wun, Lap Min. "Weight
Adjustments in Estimates for the 1999 Medicare Health Outcomes Survey." ASA Proceedings of
the Joint Statistical Meetings. 2002. 1565-1570.
Ware, John E. and Kosinski, Mark. "Interpreting SF-36® Summary Health Measures: A
Response." Quality of Life Research." 2001. Volume 10(5): 405-413, 415-420.
Technical Reports
Medicare Health Outcomes Survey: An Alternative Case-Mix Methodology (PDF, 160 KB).
The Medicare HOS program uses the outcomes of change in health status after adjustment with a
fairly complex multi-modeling case-mix methodology. The purpose of this study was to use a
theory and evidence-based hierarchical approach to develop and test an alternative case-mix
methodology that is simpler and more parsimonious.
HOS/CAHPS® Survey Integration Formative Study Design - Final Report
This document provides a preliminary assessment to determine the feasibility of integrating the
HOS and the Medicare Advantage (MA) CAHPS® surveys into one survey instrument. To
conduct this assessment, HSAG gathered and reviewed information from a variety of sources,
including 1) key stakeholders; 2) published and unpublished literature; and 3) analyses of data
from the current HOS, MA CAHPS®, and Medicare Fee-For-Service CAHPS® surveys. This
report summarizes the findings. To evaluate the feasibility of integrating the HOS and MA
CAHPS® surveys, seven key aspects of these two surveys were examined: Questionnaire
Content; Survey Administrative Protocols; Analytic Strategies; Sampling Methods; Cost and
Burden; Dissemination of the Results; and Uses of the Results. This report will help to inform
future discussions regarding the advantages and disadvantages of integration.
Imputing Physical and Mental Summary Scores (PCS and MCS) for the Veterans SF-12
Health Survey in the Context of Missing Data
This report describes a new method (modified regression estimation) for estimating the Physical
Component Score (PCS) and the Mental Component Score (MCS) from the Veterans SF-12
Health Survey in the context of missing data. The report provides a SAS® macro implementing
this method, with instructions for use of the macro.
Imputing the Physical and Mental Summary Scores (PCS and MCS) for the MOS SF-36
and the Veterans SF-36 Health Survey in the presence of Missing Data
This report compares five different methods for imputing missing data in responses to the SF-36.
The various methods are compared in terms of both variance and degree of bias.
Calculating HOS Performance Measurement Results
This document provides a detailed outline of the steps utilized for the calculation of HOS
Performance Measurement results. The Performance Measurement results are based on risk
adjusted mortality rates, and changes in physical and mental functioning and well being, among
living beneficiaries over a two-year period. SAS® code utilized for the calculation of the Cohort
III Performance Measurement results is also included.

HOS/VA (Veterans Administration) Comparison Project Part 1: Measurement
Equivalence of Medicare HOS SF-36 and VA Veterans SF-36
This paper provides evidence that SF-36 scales can be computed and compared between the
HOS and VA. Although differences exist between the two instruments, the paper's establishment
of partial metric equivalence suggests that quantitative comparisons between the two samples are
appropriate. An electronic version of the VA Veterans SF-36 is available for download: VA
Veterans SF-36 Instrument.
HOS/VA Comparison Project Part 2: Test of Reliability and Validity at the Scale Level for
the Medicare HOS SF-36 and VA Veterans SF-36
This paper provides evidence that the VA Veterans SF-36 scales and component summaries are
as reliable and valid as those generated utilizing the Medicare HOS version. The results strongly
suggest that the VA Veterans SF-36 is suitable for comparisons at the scale level with the
Medicare HOS version.

Results
Manuals
Ware, John E., Gandek, Barbara, Sinclair, Samuel J. and Kosinski, Mark A. Measuring
and Improving Health Outcomes: An SF-36® Primer for the Medicare Health Outcomes
Survey. Waltham MA: Health Assessment Lab and Quality Metric Incorporated, 2004.
This primer provides general information about the HOS: how it came to be, what its
components are, how HOS data are collected and analyzed, and how HOS results have been
used. Information on the construction, scoring, reliability, validity and interpretation of the SF36® Health Survey is summarized. Multiple tables of normative data are included to allow health
plans and others using the SF-36® to compare their data with reference norms for the Medicare
managed care population, overall and by categories such as age and gender. Examples of studies
that demonstrate the impact of interventions such as disease management and geriatric
assessment in improving or maintaining SF-36® scores are provided. Copies of the primer may
be purchased via QualityMetric's Secure Online Order Center (www.qualitymetric.com).
Peer Reviewed Articles
Ng, Judy H., Judith D. Kasper, Christopher B. Forrest, and Arlene S. Bierman. "Predictors of
Voluntary Disenrollment from Medicare Managed Care." Medical Care. June 2007. Volume 45
(6): 513-520.
Harris, Yael. "Depression as a Risk Factor for Nursing Home Admission Among Older
Individuals." Journal of the American Medical Directors Association. January 2007. Volume 8
(1): 14-20.
Bierman, Arlene S.; Ellis, Beth Hartman; and Drachman, David. "Depressed Mood and Mental
Health Among Elderly Medicare Managed Care Enrollees." Health Care Financing Review.
Summer 2006. Volume 27(4): 123-136.

Mardon, Russell E., Halim, Shaheen, Pawlson, L. Gregory, Haffer, Samuel C. "Management of
Urinary Incontinence in Medicare Managed Care Beneficiaries: Results from the 2004 Medicare
Health Outcomes Survey." Archives of Internal Medicine. May 2006. 166: 1128-1133.
Selim, Alfredo J., Kazis, L. E.; Rogers, W.; Qian, S.; Rothendler, J. A.; Lee, A.; Ren, X. S.;
Haffer, S. C.; Mardon, R.; Miller, D.; Spiro, A.; Selim, B. J.; Fincke, B. G. "Risk-Adjusted
Mortality as an Indicator of Outcomes: Comparison of the Medicare Advantage Program With
the Veterans' Health Administration." Medical Care. April 2006. Volume 44(4): 359-365.
Harris, Yael and Cooper, J. K. "Depressive Symptoms in Older People Predict Nursing Home
Admission." Journal of the American Geriatrics Society. April 2006. Volume 54(4): 593–597.
Ko, Yu and Coons, Stephen Joel. "An Examination of Self-Reported Chronic Conditions and
Health Care Status in the 2001 Medicare Health Outcomes Survey." Current Medical Research
and Opinion. November 2005. Volume 21(11): 1801-1808.
Moriarty DG, Kobau R, Zack MM, Zahran HS. "Tracking Healthy Days - A Window on the
Health of Older Adults." Preventing Chronic Disease. July 2005. Volume 2(3): 1–8.
Grace, Susan C., Shannon, Erin Dowd, Drachman, David, and Ellis, Beth Hartman. "Multiple
Cohorts Analysis of the Medicare Health Outcomes Survey, 1998-2002." Health Care Financing
Review. Spring 2005. Volume 26(3): 125-128.
Lied, Terry R. and Haffer, Samuel C. "Health Status of Dually Eligible Beneficiaries in Managed
Care Plans." Health Care Financing Review. Summer 2004. Volume 25(4): 59-74.
Ellis, Beth Hartman, Shannon, Erin Dowd, Cox, Jacquilyn Kay, Aiken, Leona and Fowler,
Brenda M. "Chronic Conditions: Results of the Medicare Health Outcomes Survey, 1998-2000."
Health Care Financing Review. Summer 2004. Volume 25(4): 75-91.
Bierman, Arlene S. "Coexisting Illness and Heart Disease Among Elderly Medicare Managed
Care Enrollees." Health Care Financing Review. Summer 2004. Volume 25(4): 105-117.
Kuo, Yong-F., Peek, M. Kristen, Raji, Mukaila A., and Goodwin, James S. "Health-Related
Social Disengagement in Elderly Diabetic Patients: Association with Subsequent Disability and
Survival." Diabetes Care. July 2004. Volume 27(7): 1630–1637.
Ellis, Beth Hartman, Bannister, Wade M., Cox, Jacquilyn Kay, Fowler, Brenda M., Shannon,
Erin Dowd, Drachman, David, Adams, Randall W. and Giordano, Laura A. "Utilization of the
propensity score method: an exploratory comparison of proxy-completed to self-completed
responses in the Medicare Health Outcomes Survey." Health and Quality of Life Outcomes.
September 18, 2003. Volume 1(47).
Arday, David R., Milton, Micah H., Husten, Corinne G., Haffer, Samuel C., Wheeless, Sara C.,
Jones, Shelton M. and Johnson, Ruby E. "Smoking and Functional Status Among Medicare

Managed Care Enrollees". American Journal of Preventive Medicine. April 2003. Volume 24(3):
234-241.
Haffer, Samuel C., Bowen, Sonya E., Shannon, Erin Dowd and Fowler, Brenda M. "Assessing
Beneficiary Health Outcomes and Disease Management Initiatives in Medicare." Disease
Management and Health Outcomes. February 2003. Volume 11(2): 111-124.
Baker, Frank, Haffer, Samuel C. and Denniston, Maxine. "Health-Related Quality of Life of
Cancer and Noncancer Patients in Medicare Managed Care." Cancer. February 1, 2003. Volume
97(3): 674-681.
Lied, Terry R., Sheingold, Steven H., Landon, Bruce E., Shaul, James A., and Cleary, Paul D.
"Beneficiary-Reported Experience and Voluntary Disenrollment in Medicare Managed Care."
Health Care Financing Review. Fall 2003. Volume 25(1): 55–66.
Moriarty, David G., Zack, Mathew M., and Kobau, Rosemarie "The Centers for Disease Control
and Prevention's Healthy Days Measures – Population Tracking of Perceived Physical and
Mental Health Over Time." Health Quality Life Outcomes, 2003. Volume 1: 37.
Schwab, T. C., Leung, K.-M., Gelb, E., Meng, Y.-Y., and Cohn, J. "Home- and CommunityBased Alternatives to Nursing Homes: Services and Costs to Maintain Nursing Home Eligible
Individuals at Home." Journal of Aging and Health. 2003. Volume 15: 353–370.
Fody-Urias, B. M., Fillit, H., Hill, J. "The Effect of a Fitness Program on Health Status and
Health Care Consumption in Medicare MCOs." Managed Care Interface. September 2001.
Volume 14(9): 58-64.
Cooper, James K., Harris, Yael and McGready, John. "Sadness Predicts Death in Older People."
Journal of Aging and Health. November 2002. Volume 14(4): 509-526.
McCall, Nancy T., Parks, Peggy, Smith, Kevin, and Griggs, Michelle. "The prevalence of major
depression or dysthymia among aged Medicare Fee-for-Service beneficiaries." International
Journal of Geriatric Psychiatry. 2002. Volume 17: 557-565.
Bierman, Arlene S., Lawrence, William F., Haffer, Samuel C. and Clancy, Carolyn M.
"Functional Health Outcomes as a Measure of Health Care Quality for Medicare Beneficiaries."
Health Services Research. December 2001. Volume 35(6) Part II: 90-109.
Cooper, James K. and Kohlmann, Thomas. "Factors associated with health status of older
Americans." Age and Ageing. November 2001. Volume 30(6): 495-501.
Bierman, Arlene S., Haffer, Samuel C. and Hwang, Yi-Ting. "Health Disparities Among Older
Women Enrolled in Medicare Managed Care." Health Care Financing Review. Summer 2001.
Volume 22(4): 187-198.

Bierman, Arlene S., Haffer, Samuel C., Hwang, Yi-Ting and Mandelblatt, Jeanne. "Elderly
Women in Managed Care: Impact of Race/Ethnicity, Education, and Income on HRQOL."
Quality of Life Research. October 2000. Volume 9(3). Published Abstract.
Haffer, Samuel C., Bierman, Arlene S., Hwang, Yi-Ting and Mandelblatt, Jeanne. "Assessing the
HRQOL of Socioeconomically Disadvantaged Elders in Medicare Managed Care." Quality of
Life Research. October 2000. Volume 9(3). Published Abstract.
Arday, David R. "Receipt of Advice to Quit Smoking in Medicare Managed Care - United
States, 1998." Morbidity and Mortality Weekly Report (MMWR). September 8, 2000. Volume
49(35): 797-801.
Stevic, Marcia O., Haffer, Samuel C., Cooper, James, Adams, Randall and Michael, James.
"How Healthy ARE our Seniors?: Baseline Results from the Medicare Health Outcomes
Survey." Journal of Clinical Outcomes Management. August 2000. Volume 7(8): 39-42.
Technical Reports
Implementing the HEDIS® Medicare Health Outcomes Survey: The Impact of Health Plan
Quality on Medicare Beneficiary Outcomes. This report assesses the relationship of plan-level
performance on HEDIS® measures of clinical processes and intermediate outcomes with changes
over two-years in the self-reported physical and mental health outcomes from the Medicare HOS
among elderly Medicare plan enrollees with diabetes, hypertension, ischemic heart disease, and
depression. This study represents one of the first attempts to directly link plan HEDIS ®
performance to outcome measures of enrollee health.
Multiple Cohorts Analysis: Longitudinal Analysis of SF-36® Summary Scores in the
Medicare Health Outcomes Survey - Final Report
This technical report examines changes in the PCS and MCS scores for beneficiaries of Medicare
Advantage (MA) Plans (formerly referred to as Medicare + Choice Organizations) who
completed a Medicare Health Outcomes Survey at yearly intervals from 1998 through 2002. This
study incorporates data from those MA beneficiaries that participated in the HOS on more than
one occasion. Trends in physical component summary and mental component summary scores
were examined for beneficiaries who completed the survey two years, three years, four years,
and five years in a row. The examination of these trends provides information on whether or not
declines in health status accelerate over time or remain constant. This information is valuable in
determining the optimal number of years to wait before conducting the follow up survey.
Evaluation of Disease Status based on Patient Self-Report in the Medicare Health
Outcomes Survey
Using data from patients who are eligible for both Medicare and VA care, this report compares
patient self-reports of chronic conditions to actual chronic conditions as documented from
diagnostic codes obtained from these patients' medical records. Accuracy of the patient selfreports was quantitatively assessed for a variety of chronic conditions, by calculating sensitivity
(the probability that patients would report the disease given its indication in the medical records),

and specificity (the probability that patients would not report the disease given its absence in the
medical records).
Evaluating the Two-Year Follow Up Health Status of Medicare Fee-For-Service
Beneficiaries Using the Health Outcomes Survey
This report presents an analysis of follow up results for the HOS, which was administered to a
sample of Medicare Fee-for-Service beneficiaries in 1998 and 2000. The primary goal of this
analysis is to assess the feasibility of using longitudinal estimates of self-reported health status
for cohorts of Medicare beneficiaries to evaluate the care provided to Fee-for-Service
beneficiaries by physician group practices or by Fee-for-Service providers in small geographic
areas.
Comparison of the Health Status of Medicare Fee-For-Service and Managed Care
Enrollees Using the HOS
This report compares Medicare Fee-for-Service and Medicare Managed Care enrollees on a
variety of health measures, including physical health status, mental health status, reports of
chronic conditions, and activities of daily living (ADLs). The report also assesses the extent to
which differences in health status are due to differences in the demographic composition of the
two populations.
MCS Outlier Evaluation Report
This project was a collaborative effort among CMS, HSAG, and NCQA. The evaluation
involved surveying all 28 outlier plans from the Cohort I Performance Measurement Results, as
well as 20 randomly selected "average" plans.
Report on the Health Status of the Medicare Disabled
For Cohort I Baseline, 279,135 Medicare beneficiaries were sampled. 167,248 seniors (age 65 or
older) responded to the survey. Additionally, 10,513 (out of a total of 18,864) disabled
beneficiaries responded to the survey. This report performs a comparison between these two
groups.
Report on the Health Status of the Medicare Dual Eligible
For Cohort I Baseline, 171,510 Medicare beneficiaries responded to the survey. Additionally,
6,247 beneficiaries enrolled in both Medicare and Medicaid completed a survey. This report
performs a comparison between these two groups.

Applications/Interventions
Peer Reviewed Articles
Trisolini, Michael G., Smith, Kevin W., McCall, Nancy T., Pope, G.C., Klosterman, M.
Evaluating the Performance of Medicare Fee-For-Service Providers Using the Health Outcomes
Survey: A Comparison of Two Methods. Medical Care. July 2005. Volume 43(7): 699-704.
McDonald, Kathie, Ma, Jifeng and Dulabone, Elaine. "Use of HOS Data in Florida." Health
Care Financing Review. Summer 2004. Volume 25(4): 93-104.

Selim, Alfredo J., Berlowitz, Dan R., Fincke, Graeme, Cong, Zhongxiao, Rogers, William,
Haffer, Samuel C., Ren, Xinhua S., Lee, Austin, Qian, Shirley X., Miller, Donald R., Spiro,
Avron, Selim, Bernardo J. and Kazis, Lewis E. "The Health Status of Elderly Veteran Enrollees
in the Veterans Health Administration." Journal of the American Geriatrics Society. August
2004. Volume 52(8): 1271-1276.
Derose, S. F. and Petitti, D. B. "Measuring Quality of Care and Performance from Population
Health Care Perspective." Annual Review of Public Health. 2003. Volume 24: 363–384.
Bierman, Arlene S. and Clancy, Carolyn M. "Health Disparities Among Older Women:
Identifying Opportunities to Improve Quality of Care and Functional Health Outcomes." Journal
of the American Medical Women's Association. Fall 2001. Volume 56(4): 155-160.
Technical Reports
Disparities in Medicare Beneficiary Outcomes: Socio-Demographic Vulnerability and
Prevalent Problems in Older Populations. This report assesses the extent to which receipt of
recommended preventive services varies by vulnerability status. Studies indicate that vulnerable
Medicare Managed Care subgroups, such as racial/ethnic minorities or low socioeconomic
populations, continue to disproportionately experience quality of care problems. Strategies to
reduce disparities have generally emphasized the importance of improving preventive services.
Using Claims Data to Identify Medicare+Choice Enrollees At Risk for a Decline in
Functional Health Status. This report presents results from a study sponsored by the Agency
for Healthcare Research and Quality to identify Medicare managed care enrollees at risk for a
decline in health status. Using HOS data and Medicare managed care administrative data, the
analysis characterized utilization of health care and developed risk models for identifying
enrollees appropriate for early medical intervention.
Report on a Longitudinal Assessment of Change in Health Status and the Prediction of
Health Utilization, Health Expenditures, and Experiences with Care for Beneficiaries in
Medicare Managed Care. This report explores longitudinal change in beneficiary physical and
mental health, bodily pain, and impaired Activities of Daily Living (ADLs) in 2002, and relates
these health measures to health care usage and expenditures in 2003. Additionally, the report
examines whether changes in health status from 2000-2002 relate to patient experience with care
ratings in 2002. In sum, longitudinal changes in health status were found to significantly relate to
future health care costs and utilizations.
The Evaluation of a Mental Component Summary Score Threshold for Depression Risk in
the Medicare Population. This report examines different thresholds of mental component
summary (MCS) scores for identifying beneficiaries diagnosed with depression, and those at risk
for depression. The results indicated a low prevalence of depression (7%) based on the diagnoses
recorded on claims data among Medicare FFS beneficiaries. Beneficiaries with depression
diagnoses had lower MCS scores than those without depression diagnoses. The results indicated

that a score of 48 represents reasonable predictive accuracy and would imply screening for 20%
of elderly beneficiaries.
The Relationship between Health Status, Utilization, and Expenditures: Comparison
between Medicare Managed Care and Fee-For-Service Beneficiaries. This report examines
possible differences in the relationship between health status, health expenditures, utilization of
services, and experiences with care between Medicare FFS and managed care (Medicare
Advantage [MA]) beneficiaries. As expected, higher expenditures are associated with lower PCS
and MCS scores, with small but statistically significant differences between managed care and
FFS. Significant differences were found between the self-reported frequency of FFS and
managed care beneficiaries' visits to doctors' offices or clinics at lower levels of physical and
mental health. Finally, managed care beneficiaries have a significantly higher probability of
providing low satisfaction ratings when compared to FFS beneficiaries.
National and State Comparisons of Health Status for Medicare Managed Care and FeeFor-Service Beneficiaries. Analysis was conducted to compare the longitudinal change of
physical and mental health status of the 2002-2004 Medicare HOS to a simulated longitudinal
change in the 2002 and 2004 CAHPS Fee-For-Service. At a national level, the results indicated
that there is not a significant difference between Medicare Fee-For-Service and Managed Care
beneficiaries in relation to the amount of physical and mental health status change for the years
examined.
Report on the Health Status of Disadvantaged Medicare Beneficiaries. This report examines
the predictors of disparities in health outcomes for Medicare beneficiaries in Cohorts II and III of
the Medicare Health Outcomes Survey (HOS).
Report on Enrollment Duration: Cohort I Baseline
This paper presents potential differences in health status between Medicare Health Outcomes
Survey (HOS) Cohort I Baseline beneficiaries with fewer than six months tenure in their health
plans and those with more than six months tenure.
Report on Mental Health Status of Managed Care Beneficiaries: Cohort I Baseline and
Follow Up
This research examines the differences between beneficiaries at high risk for depression and
those at low risk for depression sampled in the Medicare Health Outcomes Survey (HOS).
Report on the Health Status of Managed Care Smokers and Nonsmokers: Cohort III
Baseline and Follow Up
This research examines differences in physical and mental health status for beneficiaries who
were smokers and nonsmokers in Cohort III of the Medicare Health Outcomes Survey (HOS).
Report on the Comparison of Seniors in Program of All-Inclusive Care for the Elderly
(PACE) and Medicare Advantage Plans: Cohorts II, III, IV and V Baseline
This report compares the health status of beneficiaries enrolled in Program of All-Inclusive Care
for the Elderly (PACE) plans with the health status of beneficiaries enrolled in Medicare

managed care plans who participated in Cohorts II, III, IV and V Baseline (1999 to 2002) of the
Medicare Health Outcomes Survey (HOS).
Medicare HOS National Pilot Project on Depression Final Report
From 1999 to 2002, 16 M+COs and six QIOs participated in a pilot project to develop a strategy
for using the HOS results to identify and treat beneficiaries with a high risk for depression.
Claims and HOS data were used to develop a statistical profile of these high-risk beneficiaries.
Each M+CO then provided their primary care providers with a list of the high-risk beneficiaries
in their caseloads, as well as screening instruments, clinical guidelines, and treatment protocols
for depression management. The participating plans were compared to non-participating plans to
measure the impact on both process measures and HOS scores. A copy of the Pilot Project User's
Guide is available below.
The SF-36® Health Survey: A Summary of Responsiveness to Clinical Interventions
This paper provides evidence that the SF-36® scales and summary measures are sensitive
measures that can demonstrate changes in health due to various treatments, including
pharmacological, surgical, and educational interventions.
Medicare HOS National Pilot Project on Depression User's Guide
This project represents a pioneering attempt to use HOS data to help identify and manage
depression in a primary care setting. Six QIOs and 16 health plans participated in this quality
improvement pilot project.
Medicare HOS Information Synthesis
This 1999 document reviews a number of interventions that have an effect on the overall wellbeing and functional status of seniors. The intent of the review is to provide direction in
developing new interventions that are relevant to the specific needs of Medicare beneficiaries.