Summary/Response to Public Comment

CMS Response to Public Comments Received for CMS-10203

CMS received eight comments related to CMS-10203 (OMB control number 0938-0701) for the Medicare Health Outcomes Survey Field Test during the 60-day comment period.

• All commenters support CMS’s efforts to update the HOS survey instrument.

Response: CMS thanks the commenters for their support.

• One commenter supports removal of the Instrumental Activities of Daily Living (IADL) item (Q11a-c) and Healthy Days items (Q12-Q14) and another commenter does not. The latter states data from these questions help them to better understand the functional status and the disease burden their members.

Response: CMS thanks the commenters for their feedback. Clinical data, including Health Risk Assessments (HRAs), can be better used to screen for and address patient-level needs as part of an ongoing quality improvement process. CMS encourages plans that find measures such as the IADL and Healthy Days items useful to incorporate them into the HRAs.

• One commenter does not support removal of the number pain scale question (Q38) and cites a strong correlation to the physical component score (PCS) change score. They wrote that a focus on controlling pain can be an effective way to improve or maintain physical health and said the question gives additional insight into a respondent’s changing physical health.

Response: CMS agrees that a focus on controlling pain can be an effective way of improving or maintaining physical and mental health. However, clinical data such as HRAs are better suited to address patient-level needs, particularly self-reported pain. The HOS is not designed for addressing individual patient needs, see more details below.

• Two commenters stated that the HOS fails to provide actionable information for timely quality improvement and urged CMS to increase the sample size; ensure the sample represents the diversity of the Medicare population; capture contextual information to understand individual responses; address the inherit bias of self-reported data; and refine the questions to capture the goals of individuals with both complex medical and behavioral health conditions.

Response: The HOS is not designed to access individual needs or patient-level results, but rather to measure plan performance in addressing enrollees’ health needs. A comprehensive quality improvement approach goes beyond using HOS data to address concerns in specific enrollees, and instead uses data to devise approaches that improve health outcomes for all members. Clinical data, including HRAs, are better used to screen for and address patient-level needs as part of an ongoing quality improvement process.

The HOS uses random sampling to ensure an unbiased survey sample. The minimum survey measure denominators for the HOS longitudinal measures were increased from 30 to 100 to align with the three HEDIS/HOS cross-sectional measures and enhance reliability. While capturing contextual information in survey responses may be challenging, we continue to explore ways in which HOS questions can be refined to capture the goals of diverse individuals.

• One commenter offered no feedback on the 5 items currently slated for removal but repeated their suggestions on last year’s field test PRA package (CMS-10861). They requested CMS retain the proxy and living alone items, six chronic conditions (CHF, myocardial infarction, other heart conditions, stroke, Crohn’s disease, osteoporosis), and current cancer treatment items, add questions about “Stroke or Progressive Neuro-Muscular Condition such as ALS, MS, or CMT” and “Alzheimer’s disease or dementia,” and allow respondents to self-report dual status (Medicaid enrollment).

Response: Please note that this comment concerns an earlier PRA package, CMS-10861, that was approved on March 25, 2024. CMS opted to remove the proxy item from the field test instrument because research indicates HOS proxy responses are quite similar to HOS direct responses, the indicator for proxy response contributes little to baseline case-mix adjustment and is not used for performance measurement case-mix adjustment, and recent results show professional caregiver proxies account for fewer than 0.4% of HOS respondents. The living alone item was removed because some stakeholders and respondents have noted that the item makes them uncomfortable divulging information that may affect their personal security. The living alone item is not used for case-mix adjustment.

While all HOS 3.0 items removed from the field test instrument have value given the diversity of HOS respondents, to limit burden and make room for testing items with potentially greater value for longitudinal quality measurement, CMS opted to remove conditions of relatively low prevalence. Removing the items from case-mix adjustment had a negligible impact on measure scores.

CMS has taken the suggestion to add questions about “Stroke or Progressive Neuro-Muscular Condition such as ALS, MS, or CMT” and “Alzheimer’s disease or dementia” under consideration for the future. One concern is overall survey length and burden to respondents.

Finally, an enrollee’s Medicaid status, as identified from CMS’s administrative data, has historically been used in the performance measurement case-mix adjustment (for details of the case-mix process and covariates, see Appendix A in the most recent Sample Performance Measurement Report: https://www.hosonline.org/globalassets/hos-online/survey-results/hos_samplepmr_c24.pdf. CMS sees no advantage in allowing respondents to self-report dual status.

• One commenter believes the physical component score (PCS) and mental component score (MCS) coefficients can sometimes lead to unexpected and unintuitive results when interpreted individually and recommended CMS re-evaluate the coefficients used to calculate the PCS and MCS scores.

Response: While the interpretation of the PCS and MCS coefficients individually may not be intuitive in some cases, the coefficients do function together so that improved health statuses result in higher PCS and MCS scores.

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