Steve Machlin, MS Joel Cohen, Ph.D Linkage of Survey and Administrative Data to Enhance Data Quality in the Medical Expenditure Panel Survey (MEPS) Steve Machlin, MS Joel Cohen, Ph.D

Disclaimer The views expressed in this presentation are those of the authors and no official endorsement by the Department of Health and Human Services, the Agency for Healthcare Research and Quality is intended or should be inferred.

Presentation Outline Overview of MEPS survey and administrative data components Broadly describe purpose of and process for linking these components Define MEPS expenditures and estimation strategies Illustrate policy relevant applications based on MEPS expenditure data

MEPS Components Household (HC) Medical Provider (MPC) Insurance (IC) Sample survey data collected from household respondents Medical Provider (MPC) Administrative data collected from medical providers who provided care to persons in the HC Pharmacy Component (PC) collects data from pharmacies that filled prescriptions for persons in the HC Insurance (IC) Sample survey of business establishments Not pertinent to this presentation

Why Are MEPS HC/MPC Data Unique? Offers Best Available View Of the U.S. Healthcare System Internally consistent information on: Event level use and expenditures, insurance, premiums, deductibles health status, conditions, employment, income, assets socio-demographics, immigration status, family relationships information about providers and the organizations they work in Linked survey/administrative data more comprehensive than either alone

MEPS Household Component (HC) Annual survey since 1996 Collects data from a nationally representative sample of U.S. households 2016 responding sample sizes ~13,000 families ~33,000 individuals

MEPS-HC: Healthcare Utilization Data MEPS household respondents asked to report all health care events for family members during reference period for interview 5 interviews gather 2 years of health care use Reported health care events (utilization) in survey classified into the following categories: Hospital inpatient stays (IP) Office-based medical provider visits (OB) Outpatient department visits (OP) Emergency room visits (ER) Dental visits (DN) Prescription medicine purchases (RX) Home health care (HH) Other medical expenses (OM) [e.g. glasses, hearing aids]

Medical Expenditure Panel Survey (MEPS) Utilization Expenditures Household Component (HC) Medical Provider Component (MPC) Expenditures What I will be talking about today is how we get the data on expenditures, or as we like to say in the business, the ‘E’ in MEPS. We start by interviewing each household, to ask about recent medical events (utilization). Then, with their permission, we go to their providers to get detailed information about the event, particularly expenditure data, (e.g. total charge, how much was paid by the patient, how much was paid by insurance.) MPC is considered the gold standard, but we also collect similar expenditure data from HH.

The “E” in MEPS: Health care Expenditures Defined as payments to the medical provider for services provided Itemized by payment source for each event reported in MEPS-HC Out-of-pocket Private insurance Medicare Medicaid Other miscellaneous sources Total expenditure = ∑ across all sources of payment

Health Expenditure Survey Data Challenges Accurate information on payments difficult to obtain in a household survey Requires good record keeping Respondent may not have the information for a variety of reasons Much missing data in HC Household respondents better at reporting out-of-pocket than 3rd party payer amounts

MEPS Medical Provider Component (MPC) Sample of providers from whom HC sample persons received medical care Need written permission from HC person MPC not designed to produce stand-alone nationally representative dataset Administrative data collected from providers’ billing offices and from pharmacies key data collected are amounts providers were paid for events reported in the HC conducted year following survey data year Linked to HC to develop more complete/accurate MEPS expenditure data

Sources of expenditure data by event type HC (Survey) MPC (Admin) Office-based: physician  Office-based: non-physician Inpatient Outpatient ER Dental RX Home health: agency Home health: paid independent Other medical

MPC Sampling for Selected Provider Types Sampling rates vary by provider type 100% of hospitals where sample persons visited/stayed (~3,000 in 2016) ~ 50% of office-based physicians (~13,000 in 2016) targeted oversamples of selected types of persons and providers 100% of pharmacies (~8,000 in 2016)

HC-MPC Matching Process: Inpatient and Office Visits HC and MPC are very different data collection processes General approach Determine “best” HC-MPC event match among all possible event pairs within block groups Block Group: Unique combination of sample person and provider contact group IDs

HC-MPC Matching Variables: Inpatient Stays and Office Visits Interview round Date of event Event type Surgery/radiology/lab Medical condition(s) treated Length of stay (inpatient events) Dr. specialty (physician office visits)

Matching HC and Pharmacy Data No common drug identifier is shared by HC and Pharmacy data A Generic Product Identifier (GPI) code is assigned to each HC and pharmacy reported drug to facilitate matching Drug names reported in HC coded into GPI National Drug Codes (NDC) reported by pharmacies coded into GPI The matching process is complicated also, but I will give you a brief overview. Because there is no common identifier to link the PC data to the HC, the drugs on both sides are coded to the Generic Product Identifier (GPI) code. The GPI is assigned based on the medication name from the household, and the NDC from the pharmacy. The GPI is a hierarchical description of the drug. Typically, households report an entire drug name (complete GPI), in which case matching is straightforward. However, when the information provided by the household or the pharmacy is not complete, we go thorugh a step-by-stpe impuation process. You can find the details of this impatiion process in the methodaolgy report. Also, for about 40% of the household members, we do not have any pharmacy information because either they did not give us permission or the pharmacy did not provide us any information or correct information. IN those cases we impute pharmacy information from other memebers with PC information using the GPI. You can find the details in amethodolgy report that I will describe at the end of this talk. Utilization is from the household because not all people allow MEPS to contact their pharmacy. Plus, not all contacted pharmacies participate. Payment data comes from pharmacies because this is a more reliable source. The pharmacies have transaction records, whereas the households may have recall issues, or not keep detailed records, or not know how much their insurance paid. People on Medicare or Medicaid or those who use federal pharmacies may have no idea how much the drug cost apart from the copayment.

General Priority of MEPS Expenditure Data Source 2 1 Household Component (HC) Medical Provider Component (MPC) Utilization Expenditure Data Expenditure Data Imputation (maximize use of MPC data as donors) 3

Expenditure Imputation: Inpatient Stays and Physician Visits Separately by event type Predictive mean matching (PMM) approach used to pair donor/recipient records Dependent Variable: Total Expenditures Independent Variables: Total Charge (if known) Event level (e.g. various services provided) Inpatient Stays: Length of Stay Physician Visits: Specialty Type Person level (e.g. insurance coverage, health status) County level (e.g. income, MSA status) PMM “nearest neighbor” used for final donor/recipient pairing; constrained to same insurance type(s)

Expenditure Imputation: Prescribed Medicines Donor/recipient records are paired by GPI Further matching on many factors including: Pharmacy name Insurance coverage Health conditions Demographics Geographic location Number of fills during interview round Impute donor payments to recipient records

MEPS Final Expenditure Data Source for Selected Event Types, 2016 Inpatient Stays Physician Office Visits Prescribed Meds Fills Total # HC reported events 2,765 123,441 319,685 Percent Distribution by Data Source HC DATA 4.0% 10.2% -- MPC DATA 55.4% 37.2% 45.4% FULLY IMPUTED 34.6% 37.3% 37.5% PARTIALLY IMPUTED 6.0% 15.2% 17.1%

Research Uses of the Medical Expenditure Panel Survey

Who Uses MEPS Data? HHS Health services research community OMB CBO CRS Treasury BLS Census VA Health services research community Academic and research organizations Trade Associations States Consumers

How Are the Data Used? Used in calculating the National Health Expenditure Accounts All large health policy simulation models rely on MEPS CBO, Treasury, Urban, Lewin Healthcare policy decisions based on MEPS Frequent assistance on specific questions to ASPE, Treasury, CBO, and others State Medicaid policy No data source serves as the basis for more Health Affairs articles

Expenditures by Event Type

Expenditures by Source of Payment

Concentration curve of health care expenditures, U.S. civilian noninstitutionalized population, 2016 99% Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, Household Component, 2016

Mean total expenditure per person by percentile of spending, 2016 Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, Household Component, 2016

Ten Highest Spending Conditions, 2015 Total Expenses ($ in millions) # Persons (in thousands) Total expenses ($)/person Heart disease $113,438 24,898 $4,556 Trauma-related disorders $102,672 38,134 $2,692 Mental disorders $98,819 49,608 $1,992 Diabetes mellitus $89,666 26,356 $3,402 Osteoarthritis and other non-traumatic joint disorders $81,203 40,593 $2,000 Cancer $80,249 16,495 $4,865 COPD, asthma $78,557 48,103 $1,633 Back problems $56,466 24,933 $2,265 Infectious diseases $56,031 18,946 $2,957 Hypertension $52,229 63,461 $823

Figure 1. Total expenses for all outpatient prescription opioids and the top four opioid products*, U.S. civilian noninstitutionalized adult population, 2015 Dollars in billions *Ranked by total expenses in 2015 Note: Estimates are for the U.S. civilian noninstitutionalized population. Source: Center for Financing, Access, and Cost Trends, AHRQ, Household Component of the Medical Expenditure Panel Survey, 2015

Total person level prescribed medicine expenditures for persons with prescribed medicine fills, 2009-2016 To authors: Should the median value for 2016 ($326) have an asterisk? * Estimates for 2009 and 2016 are statistically different at the p<0.05 level. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, Household Component, 2009-2016

Out-of-pocket prescribed medicine expenditures for persons with prescribed medicine fills, 2009-2016 * Estimates for 2009 and 2016 are statistically different at the p<0.05 level. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, Household Component, 2009-2016

Standardized Inpatient Payments Payment when the primary payer was private insurance was for many years approximately 10 to 20 percent above that when the primary payer was Medicare. However, this difference widened substantially starting in the early 2000s. Note: Medicaid does not include DSH or other supplemental payments. Recent work published in Health Affairs suggests that total Medicaid reimbursement per stay may be larger than Medicare. Selden, Karaca, Keenan, White, and Kronick, “The Growing Difference Between Public And Private Payment Rates For Inpatient Hospital Care,” Health Affairs, December 2015.

Percentage of Nonelderly Adults with Employer-Sponsored Insurance Facing Health Care Burden Exceeding 20 Percent of Family Income, by Income and Deductible Level, 2011-2013 SOURCE Abdus et al., 2016. Authors’ calculations of data from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey, 2011–13. NOTES The sample includes all nonelderly adults (ages 19–64) enrolled in employer-sponsored insurance plans for a full year who provided valid information about their plan types and who did not have a mix of plans with different levels of deductibles. Financial burden is defined as the ratio of total annual family out-of-pocket spending for health care services and premiums divided by total annual after-tax family income. HDHP is high-deductible health plan. HSA is health savings account or similar special fund or account. FPL is federal poverty level.

Summary MEPS expenditure data based on linkage of survey and administrative data Richer data than either alone Powerful database for informing policy related to medical care use and expenditures Concentration of expenditures Expenditures by condition Cost of prescription drugs Healthcare spending burden on individuals/families

Contact Information Steve Machlin: steven.machlin@ahrq.hhs.gov Joel Cohen: joel.cohen@ahrq.hhs.gov MEPS Website www.meps.ahrq.gov