Evaluating outcomes of care and targeting quality improvement using medicare health outcomes survey data

The Medicare Health Outcomes Survey (HOS) provides a rich source of outcomes data on the Medicare Advantage (MA) program for the US Department of Health and Human Services, managed care organizations participating in Medicare, quality improvement organizations, and health services researchers working to improve quality of care for Medicare enrollees. Since 1998, the Centers for Medicare and Medicaid Services has collected longitudinal functional status information to assess the performance of Medicare managed care organizations. This introduction reviews the goals of the HOS program, how the HOS supports health care reform, and outlines recent HOS studies exploring data applications for monitoring outcomes and implementing quality improvement activities.     

Assessing Beneficiary Health Outcomes and Disease Management Initiatives in Medicare

Introduction: Provisions in the Balanced Budget Act of 1997 directed the US Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) to begin focusing attention on the standardized measurement of health outcomes of Medicare beneficiaries as well as testing the effectiveness of various disease management interventions at improving these outcomes.The CMS, in collaboration with the US National Committee for Quality Assurance, developed the Medicare Health Outcomes Survey (HOS) as the first health outcomes measure from the patient’s perspective in Medicare managed care. This new source of data, using the Medical Outcomes Study Short Form 36-Item Health survey (SF-36®) as its core measure, provides valuable standardized health outcomes information about Medicare managed care enrollees in general and the chronically ill in particular. Study design: From May through July 1998, a longitudinal, self-administered survey which utilized the SF-36® (a health status measure which assesses both physical and mental functioning) was administered to 1000 randomly sampled Medicare beneficiaries who were continuously enrolled for a 6-month period in a Medicare managed care health plan. This cohort was re-surveyed from April though June of 2000. We analyzed data from the cohort I baseline and re-measurement analytic sample of 51 700 individuals. Results: Using the change in SF-36® physical component summary scores and mental component summary scores over a 2-year period, we demonstrated that the presence of chronic disease has a negative impact on both the physical and mental health functioning of Medicare managed care enrollees over time. With few exceptions, the negative effect of chronic disease on physical and mental health is found to be independent of gender, race, and socioeconomic status as measured by level of educational attainment. Differences in mean health status scores across levels of chronic conditions suggest that preventing the onset of disease is best for maintaining optimal health. Conclusions: Disease management interventions which are properly designed and implemented have been shown to measurably improve patient outcomes by providing high quality, cost-effective care. Recognizing the need for standardized outcome measures and scientifically validated disease management interventions, the CMS has taken a leadership role by developing and implementing the Medicare HOS and disease management demonstration projects.     

Health outcomes. New quality measure for Medicare.

OBJECTIVE: A new measurement of health care quality for Medicare beneficiaries has been implemented by the Health Care Financing Administration (HCFA). This paper describes the program, presents baseline data and highlights associated issues. DESIGN: The Health Outcomes Survey (HOS) is a longitudinal cohort mail survey. Changes in population health status after 2 years will be evaluated on an individual plan level. SETTING: Two-hundred and eighty-seven US Medicare managed care plans. MAIN OUTCOMES MEASURES: Physical component and mental component summary scales derived from the SF-36. FINDINGS: Baseline data documented lower health status in older populations, while functional limitations and disease prevalence were higher. Among different plans, mean functional levels were found to be similar, although a few plans contained populations with exceptionally low levels. These data do not support the assertion that enrolees in for-profit plans are healthier than non-profit plans. CONCLUSIONS/IMPLICATIONS: The HOS is the first large-scale program to evaluate health outcomes among older Americans. HCFA recognizes several technical and policy issues. Technical issues include possible biased reporting for subpopulations, the validity of proxy responses and respondent burden. Policy issues concern the appropriateness of using a generic measure such as the SF-36 and how much change in health status can be attributed to quality of health care. HCFA plans to extend the HOS to beneficiaries in traditional Medicare. The HOS project is expected to encourage more efforts to maintain or improve the health status of the Medicare managed care population.     

Measuring and improving health outcomes in Medicare: the Medicare HOS program

The Medicare Health Outcomes Survey (HOS) (originally called the Health of Seniors Survey) was developed as a longitudinal performance measure to assess the physical functioning and mental well being of Medicare beneficiaries over time. The survey was implemented nationally in Medicare managed care organizations (MCOs) as part of Medicare HEDIS, 3.0/1998 and continues today. In 1998, a pilot test of the HOS in Medicare FFS was conducted; the pilot test concluded in 2001. This overview discusses the importance of functional status assessment, reviews the goals of the HOS, and explains how researchers and quality improvement professionals are using the data to explore functional status measurement issues, describe policy and programmatic implications for CMS, and identify opportunities to improve health care practice.     

Use of HOS data in Florida

The Medicare Health Outcomes Survey (HOS) is a longitudinal cohort study that assesses physical and mental functioning of Medicare enrollees in MCPs. Realizing the potential of HOS data to improve health care, the Florida Medicare Quality Improvement Organization (QIO) analyzed HOS scores and shared them with M+COs to assist in evaluating the efficacy of their disease management programs. The QIO also discusses additional uses for HOS data such as cross-linking with a patient satisfaction survey and sharing with health care organizations that collaborate with the QIO.     

The dual enrolled as a disadvantaged population: developing culturally informed interventions for Tennessee Medicare/Medicaid women

The Centers for Medicare and Medicaid Services (CMS) have begun a major national initiative to reduce disparities in health care for the underserved through their contracts with state quality improvement organizations (QIOs). This initiative has translated into state-level projects that are, in many cases, investigating these populations to determine how best to address their health care deficiencies and improve the quality of their care. Tennessee's campaign, coordinated by the Center for Healthcare Quality (CHQ), the state's QIO, focused on the use of formative research to gain insights into diversity among the underserved in different settings across the state. Results aided the design of a series of site-appropriate interventions aimed at improving the utilization of mammography screening among Tennessee's Dual Enrolled: Medicare beneficiaries who are also enrolled in Medicare.     

Reporting a health quality improvement project for reducing the disparity in screening mammograms among senior African-American women

Despite intensive efforts by the established medical community to offer preventive health practices to minority populations, there remains a significant disparity in utilization of many of these services. Between African-American and Caucasian women there exists a significant disparity in the use of screening mammography. Under contract by the Centers for Medicare & Medicaid Services, Quality Improvement Organizations (QIOs) have been charged with reducing disparities in health care among identified minority populations within each state. Quality Insights of Delaware, the QIO for the state, has developed a project that utilizes a collaboration with African-American women and community resources in an effective outreach program to the targeted population.     

From Adversary to Partner: Have Quality Improvement Organizations Made the Transition?

OBJECTIVE: To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement. DATA SOURCE: Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002. STUDY DESIGN: We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness. PRINCIPLE FINDINGS: More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators. CONCLUSIONS: Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians.     

Measurement comparisons of the medical outcomes study and veterans SF-36 health survey

The Medicare Health Outcomes Survey (HOS) uses the Medical Outcomes Study (MOS) SF-36 among beneficiaries enrolled in Medicare managed care programs, whereas the Department of Veterans Affairs (VA), Veterans Health Administration (VHA) has administered the Veterans version of the SF-36 for quality management purposes. The Veterans version is comparable to the MOS version for 6 of the 8 scales, but distinctly different in role physical (RP) and role emotional (RE) scales. The gains in precision for the Veterans SF-36 provide evidence for the use of this version in future applications for assessing patient outcomes across health care systems.     

Health care use and expenditures of Medicare HMO disenrollees

We examine the impact of the first wave of Medicare health maintenance organization HMO withdrawals. With data from CMS and United Health Group, we estimate use and expenditure changes between 1998 and 1999 for HMO enrollees who were involuntarily dropped from their plan and returned to fee-for-service (FFS) Medicare using a difference-in-difference model. Compared to those who voluntarily left an HMO, involuntarily disenrolled beneficiaries had higher out-of-pocket expenditures, an 80 percent decrease in physician visits, 38 percent higher emergency room (ER) use and a higher probability of dying. The results suggest beneficiaries face significant costs and reduced health outcomes from unstable Medicare managed care markets.     

What are Medicare managed care plans doing to measure and improve quality of care?

To explore managed care plans' efforts to assess and improve quality of care for Medicare beneficiaries, the authors surveyed managed care plans with risk contracts for Medicare beneficiaries in 20 large metropolitan areas in January 1998. The survey inquired about: (1) the health plans' efforts to assess and improve quality of care for specific underuse, overuse, and misuse problems; (2) how the health plans assessed functional status of enrollees, and (3) the quality improvement program they believed had the greatest impact on the health of enrollees. The managed care plans reported a heterogeneous mix of quality improvement activities ranging from poorly developed to very sophisticated. The vast majority of the more sophisticated programs addressed problems with underuse of services rather than overuse or misuse.     

Strategic opportunities in the oversight of the U.S. hospital accreditation system

Hospital accreditation and state certification are the means that the Centers for Medicare & Medicaid Services (CMS) employs to meet quality of care requirements for medical care reimbursement. Hospitals can choose to use either a national accrediting agency or a state certification inspection in order to receive Medicare payments. Approximately, 80% of hospitals choose the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The purpose of this paper is to analyze and discuss improvements on the structure of the accreditation process in a Principal-Agent-Supervisor framework with a special emphasis on the oversight by the principal (CMS) of the supervisor (JCAHO).     

Beneficiary decisionmaking: the impact of labeling health plan choices

One critical health plan decision concerns choosing an original Medicare plan or a Medicare managed care plan. Evidence suggests that people are confused by the phrase "Original Medicare plan." Using focus group and Q-sort methodology, the authors sought to identify a name for the Medicare fee-for-service (FFS) product. Two key insights were gained. First, participants used the word "Medicare" to name the FFS product. Second, participants did not choose between two plans. Rather, they decided between supplemental insurance and a managed care product. These factors should influence how CMS "brands" not only the FFS product but also the overall Medicare program.     

Case management of the elderly in a health maintenance organization: the implications for program administration under managed care

Kaiser Permanente initiated a two-year demonstration ambulatory case management program in its Ohio region to evaluate five outcomes: perceived health status, functional status, and satisfaction with care, service use, and service costs. Expected results were not consistently obtained for the five outcome measures. Treatment group members did not, however, experience the functional status impairments or decline in health status perceptions reported by the control group during the study period. The unexpected finding that costs were not affected may be attributed to the type of case management intervention used in the demonstration program. This study is broadly applicable to managed care settings facing the challenge of developing programs to minimize the risk for bearing the costs of the Medicare beneficiaries' overall health when all services are not covered. Managed care administrators should be favorably disposed to implementing a case management model with the potential for affecting functional status, the most significant predictor of expensive continuing care for this cohort of Medicare beneficiaries, while working to develop more effective protocols and resource control strategies.     

Raising Awareness of Medicare Member Rights Among Seniors and Caregivers in California

Many Medicare recipients do not understand their health care rights. Lumetra, formerly California''s Medicare quality improvement organization, developed a multifaceted outreach program to increase beneficiary awareness of its services and of the right to file quality-of-care complaints and discharge appeals. Layered outreach activities to Medicare members and their caregivers in 2 targeted counties consisted of paid media, direct mailings, community outreach, and online marketing. Calls to Lumetra''s helpline and visits to its Web site—measures of beneficiary awareness of case review services—increased by 106% and 1214%, respectively, in the targeted counties during the 4-month outreach period. Only small increases occurred in nontargeted counties. Increases in quality-of-care complaints and discharge appeal rates were detected during a longer follow-up period.THE MEDICARE POPULATION will grow considerably as baby boomers (persons born between 1946 and 1965) begin entering the program, increasing the demand for geriatric health care services and for clear information about Medicare benefits and rights. The Centers for Medicare and Medicaid Services contracts with quality improvement organizations (QIOs) to protect and improve care for Medicare beneficiaries.¹ This includes responding to quality-of-care complaints and discharge appeals (hereafter, complaints and appeals).² Studies have found that many Medicare members have a limited understanding of their rights and of QIO services, and complaint and appeal rates are low.^3–5 QIOs have historically conducted outreach to improve beneficiary awareness, but the effectiveness of these efforts is unknown.⁴ Lumetra, formerly California''s QIO, received funding from the Centers for Medicare and Medicaid Services to develop, implement, and evaluate outreach activities to increase beneficiary awareness of the QIO case review program. We assessed the effectiveness of this outreach program.

KEY FINDINGS

• ▪ Multifaceted outreach activities directed to Medicare members and their caregivers dramatically increased quality improvement organization helpline calls and Web site visits during the 4-month outreach period.
• ▪ Quality-of-care complaint and discharge appeal rates increased during a longer (7-month) follow-up period.
• ▪ Helpline callers were most likely to have learned about Lumetra through direct mail interventions (postcard or Medicare rights booklet).
• • Helpline caller responses indicated that calls were also prompted by radio and newspaper ads.

     

Home health care outcomes under capitated and fee-for-service payment

In this article, case-mix-adjusted outcomes of home health care are found to be superior for Medicare fee-for-service (FFS) patients relative to Medicare health maintenance organization (HMO) patients. The superior outcomes for FFS patients were accompanied by higher utilization and cost of home health services, suggesting a volume-outcome (or dose-response) relationship that was further substantiated by within-HMO and within-FFS analyses. The findings suggest that greater attention should be paid to both outcome-based quality assurance and managed care practices that may be overly restrictive in terms of the use of home health services.     

The outcomes movement and the role of health information managers

The resounding demand that health care organizations demonstrate their effectiveness in providing quality patient services is being voiced by federal and state governments, managed care organizations, the Joint Commission on Accreditation of Healthcare Organizations, and businesses and insurers purchasing and paying for health care services. The outcomes movement arose in response to these demands and is intended to provide a means for increasing medical effectiveness and reducing costs. The article presents an overview of the outcomes movement and discusses the use of outcomes data, the challenges and issues associated with outcomes assessment, and how health information managers can play a role in facilitating outcomes assessment. It suggests areas of professional development that health information managers may wish to explore.     

Preventive Services in a Medicare Managed Care Environment

The results of a four year demonstration project of preventive services for Medicare managed care enrollees suggest that health promotion programs can impact health behaviors and outcomes. The study provided selected preventive services to 1,800 Medicare enrollees in a managed care environment. Participants were randomly assigned to control and experimental groups with the experimental group receiving an intervention service package and the control group usual care. The results included enhanced health behavior practices, lower depression, and higher immunization rates among those individuals in the experimental group. This study suggests that selected preventive services can be provided in a managed care environment to Medicare enrollees with likely positive health status and utilization outcomes.Graduate School of Public Health, College of Health and Human Services, San Diego State University, San Diego, CA 92182-4162     

Who Switches from Medigap to Medicare HMOs?

OBJECTIVE: To determine the factors affecting whether Medigap owners switch to Medicare managed care plans. DATA SOURCES: The primary data were the 1993-1996 Medicare Current Beneficiary Survey (MCBS) Cost and Use Files. These were supplemented by data available from the Centers for Medicare & Medicaid Services (CMS) website. STUDY DESIGN: Individuals on the MCBS files with Medigap coverage in the period 1993-1996 were included in the study. The person-year was the unit of analysis. We used multivariate logistic regression analysis to determine whether or not a Medigap owner switched to a Medicare-managed care plan during a particular year. Independent variables included measures of affordability, need for services, health insurance benefits, sociodemographics, and supply of managed care plans. PRINCIPAL FINDINGS: We did not detect strong evidence that beneficiaries in poorer health were more likely than others to switch from Medigap coverage to Medicare-managed care. In addition, higher Medigap premiums did not appear to induce beneficiaries to switch into managed care. CONCLUSIONS: We examined selection bias in joining managed care plans among the subset of Medicare beneficiaries who have Medigap policies. No strong evidence of selection bias was found in this population. We conclude that there was no evidence that the Medigap market is becoming prohibitively expensive as a result of unfavorable selection.