The CMS Health Outcomes Survey (HOS) is Evolving: Seven Essential Updates You Need to Know!

Get ready for the upcoming CMS Health Outcomes Survey (HOS) cycle! Starting from July 15 and running through November 1, 2024, this annual process engages a random sample of 1,200 Medicare Advantage members from plans with 500 or more enrollees. Two years later, the same cohort receives a Follow-up survey to assess changes in physical and mental health status.

Lost in the shuffle of broader methodological changes and headline-grabbing topics such as Tukey, guardrails, and associated litigation, CMS has been diligently concentrating on HOS, actively codifying and proposing substantial changes to the HOS survey in recent and forthcoming star years. With more than a quarter of your weighted stars score derived directly from self-reported member survey data (CAHPS & HOS), here are seven pivotal changes & updates that warrant your attention!

1. New HOS Measures: CMS is considering adding new longitudinal measures to the Ratings, such as Physical Functioning Activities of Daily Living (PFADL), a change that would significantly impact the weighted scores derived from member-reported survey data, making the weight of HOS measures alone equivalent to nearly all the Part D clinical measures combined!

TIP: CMS included rates for Physical Functioning Activities of Daily Living (PFADL) in the SY24 HOS Star Rating’s Validation table along with the 3 HEDIS/HOS measures & Improving Physical & Mental Health. Check out your contracts performance!

2. Contract Year 2022 MA and Part D Final Rule:

• IMH & IPH Changes: CMS revamped the case mix adjustment logic for HOS outcomes measures. Previously, an "all or nothing" approach was employed, discarding all case-mix variables if any single variable was missing. The updated method now utilizes mean value imputation, substituting missing variables with the mean value of that adjuster within the same contract's HOS sample, akin to CAHPS methodology. This enhancement aims to reduce data loss, leading to more comprehensive analysis, increased accuracy, better representation of the beneficiary population, and improved consistency.
• The minimum survey measure response denominators for IMH & IPH were increased from 30 to 100, aligning these longitudinal measures with the 3 HEDIS/HOS measures & enhancing reliability.
• Future Plans: In addition to considering PFADL & other PROMs, the agency is considering replacing IPH & IMH measures with simpler patient-reported outcome measures that reduce overall complexity.

3. Declining HOS Response Rates: Amid declining HOS response rates, which fell from 46.7% in 2015 to an all-time low of 27.6% in 2022,many small to mid-size health plans noted an increase in unreportable HEDIS-HOS measures due to data scarcity. CMS's research suggests that incorporating a web-based survey mode could boost response rates and a field test of this modality is planned per their June 26, 2023 Notice. However, a recent Press Ganey preliminary peek at CY 2024 CAHPS response rates suggest many new e-respondents were prior mail respondents rather than new ones, raising questions about the expected HOS uptick. (NOTE: Analysis only included PG BoB & results through May, 2024. Final, national results may vary).

Declining response rates combined with the 1/15/2021 Final Rule raising minimum required responses from 30 to 100, may result in additional health plans grappling with "not enough data available" when IPH & IMH return in SY26.

TIP: Review prior year HOS Follow up reports & consider oversampling for any contracts near or below the 100 member threshold.

4. The CMS Proposed HOS Field Test, as outlined in the 2023 Notice Federal Register / Vol. 88, No. 207, aims to evaluate new survey items and assess the impacts of new content and a web-based mode on response patterns and measure scores. According to CMS, the field test will employ a Multi-mode protocol, starting with a web-based survey as the initial mode of administration, followed by mail, telephone, or both for web non-respondents. Additionally, 20 existing HOS questions may be replaced with new content in the questionnaire. The new survey content may include:

• PROM Physical Function Items: These will evaluate broader functional impairment among MA enrollees, potentially enhancing the PFADL measure.
• General Anxiety Disorder Items: These will measure anxiety, providing a more comprehensive mental health assessment.
• Health-Related Social Needs Items: This section will focus on Social Determinants of Health (SDoH), aligning with CMS's health equity goals.

5. Expanding Survey Methods Without Rulemaking: Under the Contract Year 2025 Final Rule, CMS has introduced non-substantive measure updates (§§?422.164(d) and 423.184(d)), allowing for the expansion of survey methods without formal rulemaking. For instance, electronic survey methods such as web-based surveys can now be added as a non-substantive change. This change applied immediately for the 2025 Star Ratings CAHPS measures, but CMS called out flexibility to include electronic modes for future HOS surveys.

TIP: Review the CY 2024 CAHPS response data to gauge potential HOS impact. Assess electronic response rates and address digital literacy by enhancing support for members with low digital skills. Ensure access for subgroups with high LIS, Dual, and Disabled enrollment to mitigate disparities.

6. HOS & CAHPS Appeals Restrictions: In the 2025 Final Rule, both HOS and CAHPS survey data accuracy were added to the list of measures that cannot be appealed as they undergo validation and audit processes. CMS emphasizes that approved vendors adhere strictly to protocols for conducting HOS & CAHPS surveys. Moreover, the perspectives captured in these surveys are deemed accurate and non-disputable representations of beneficiaries' experiences.

7. Advancing Health Equity: CMS is gearing up for significant updates in the 2027 Star Ratings, including a shift from the star ratings reward factor to the HEI reward. This revamped approach focuses on the quality measure performance specifically for LIS dual & disabled members over a 2-year measurement period. As mentioned earlier, CMS is contemplating a HOS field test encompassing questions centered on health-related social needs (HRSN) like transportation availability, food insecurity, and housing instability, underscoring the agency's commitment to measuring and addressing health equity. Furthermore, CMS is mulling over development & addition of additional longitudinal HOS measures related to mental health & SDoH, citing alignment with CMS’ health equity goals.

While the HEI currently assesses the performance for SRF of duals, LIS, and disabled beneficiaries, the agency intends to expand this methodology to include additional SRF, but admits data for this expansion is currently lacking.

Interesting Thought: Could data from future longitudinal HOS measures be extrapolated across contracts & used as indicators for additional SRF in the HEI, enhancing the program's effectiveness in addressing health equity and improving outcomes for vulnerable populations?

The feasibility and implementation of such an approach would depend on several factors, including data accuracy, consistency, and alignment with CMS guidelines and objectives…. But, an interesting thought none-the-less. ??

Best of luck with the fielding of your CY 2024 HOS surveys, and remember - this year's follow-up survey results determine your SY 2026 IPH & IMH scores!

Feel free to reach out for help with your HOS related questions, insights, for help with strategy, or just to chat! [email protected]