The Medical Expenditure Panel Survey: Data Resources to Inform Research & Policy Jeffrey Rhoades, Ph.D.

MEPS History 1977 National Medical Care Expenditure Survey 1977 National Medical Care Expenditure Survey 1987 National Medical Expenditure Survey 1987 National Medical Expenditure Survey 1996 Medical Expenditure Panel Survey (annual) 1996 Medical Expenditure Panel Survey (annual)

MEPS Survey Components MEPS-HC -- Household Component MEPS-HC -- Household Component MEPS-MPC -- Medical Provider Component MEPS-MPC -- Medical Provider Component MEPS-IC -- Insurance Component MEPS-IC -- Insurance Component

Medical Expenditure Panel Survey – Household Component Annual Survey of 14,000 households: provides national estimates of health care use, expenditures, insurance coverage, sources of payment, access to care and health care quality Permits studies of: Distribution of expenditures and sources of payment Distribution of expenditures and sources of payment Role of demographics, family structure, insurance Role of demographics, family structure, insurance Expenditures for specific conditions Expenditures for specific conditions Trends over time Trends over time

MEPS-Household Component Survey Design Sub-sample of respondents from the previous year’s National Health Interview Survey (NHIS), sponsored by NCHS Sub-sample of respondents from the previous year’s National Health Interview Survey (NHIS), sponsored by NCHS Representative of the civilian non- institutionalized population of the US Representative of the civilian non- institutionalized population of the US Collects data for 2 years of healthcare usage from each panel Collects data for 2 years of healthcare usage from each panel 5 in-person interviews over 2 ½ year period using CAPI technology 5 in-person interviews over 2 ½ year period using CAPI technology Person and family level data collected Person and family level data collected Interviews average 90 minutes with a range of one to four hours Interviews average 90 minutes with a range of one to four hours

MEPS Panel Design: Data Reference Periods Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4 Panel 12 Round 3 Round 4 Round 5 Panel 13 Round 1 Round 2 Round 3 Round 4 Round 5 Panel 14 Round 1 Round 2 Round 3 Round 4 Round 5 Panel 15 Round 1 Round 2 Round 3 Sample Size N = 31,262N = 34,920N = 31,228 N is equal to the number of people with a positive person weight on the file.

MEPS-HC Core Interview Content Demographics Demographics Charges and Payments Charges and Payments Health Status Health Status Conditions Conditions Utilization Utilization Employment Employment Health Insurance Health Insurance

MEPS- HC Supplemental CAPI Sections Sections asked in rounds 2 and 4: Access to care Access to care Child preventive health Child preventive health Satisfaction with health plans & providers Satisfaction with health plans & providers Sections asked in rounds 3 and 5: Assets (round 5 only) Assets (round 5 only) Income Income Preventive Care Preventive Care Priority conditions Priority conditions

MEPS-HC Supplemental Paper Questionnaires Diabetes Care Survey (DCS) Diabetes Care Survey (DCS) Given once a year to each adult identified as having diabetes Given once a year to each adult identified as having diabetes Adult SAQ Adult SAQ Given once a year to each adult 18 years old and older Given once a year to each adult 18 years old and older Cancer SAQ Cancer SAQ – Given only in Panel 15 round 5 and Panel 16 round 3 to each person identified as having cancer

Levels of MEPS-HC Public Use Files Person Level - detailed person information Person Level - detailed person information Event Level - detailed event level information Event Level - detailed event level information Condition Level - detailed condition information Condition Level - detailed condition information Job Level - detailed job information Job Level - detailed job information

MEPS-HC Caveats and Limitations Sample size limitations preclude some analyses Sample size limitations preclude some analyses Typically, one respondent provides data for the entire household Typically, one respondent provides data for the entire household Household respondents may not be able to report accurately certain types of information Household respondents may not be able to report accurately certain types of information – type of health plan – detailed event information – diagnoses

MEPS Medical Provider Component (MPC) - Purpose Compensate for household item non-response Compensate for household item non-response Accuracy and detail Accuracy and detail Imputation source Imputation source Methodological studies Methodological studies

MEPS-MPC (Medical Provider Component) Survey of medical providers linked to respondents of the HC Survey of medical providers linked to respondents of the HC Collects data that household respondents cannot accurately provide, such as dates of visit, diagnosis and procedure codes, charges and payments Collects data that household respondents cannot accurately provide, such as dates of visit, diagnosis and procedure codes, charges and payments The Pharmacy Component (PC), a subcomponent of the MPC, collects drug detail information, including National Drug Code (NDC) and medicine name, date filled and sources and amounts of payment The Pharmacy Component (PC), a subcomponent of the MPC, collects drug detail information, including National Drug Code (NDC) and medicine name, date filled and sources and amounts of payment The MPC is not designed to yield national estimates. It is primarily used as an imputation source to supplement household reported expenditure information. The MPC is not designed to yield national estimates. It is primarily used as an imputation source to supplement household reported expenditure information.

Medical Provider Component (MEPS) Data Collected for: – – Physician Office Visits – – Outpatient Department Visits – – Hospital Inpatient Stays – – Emergency Room Visits – – Prescribed Medicines (Pharmacy Component) – – Home Health Agency Care Not collected for: – – Non-physician Office Visits – – Dental Visits – – Home Health - Independent Providers – – Other Medical Expenses

MEPS-IC Survey Nationwide, annual survey of both private and public sector establishments Nationwide, annual survey of both private and public sector establishments Funded by the Agency for Healthcare Research and Quality (AHRQ) Funded by the Agency for Healthcare Research and Quality (AHRQ) Conducted by the U.S. Census Bureau Conducted by the U.S. Census Bureau Survey data available for 1996 through 2010 (except 2007) Survey data available for 1996 through 2010 (except 2007)

MEPS-IC (Insurance Component) An independent survey of employers and unions not linked to the household survey An independent survey of employers and unions not linked to the household survey The sample contains information from about 44,000 establishments and supports national and state-level estimates for all 50 states. The sample contains information from about 44,000 establishments and supports national and state-level estimates for all 50 states. Employer-sponsored health insurance measures: Employer-sponsored health insurance measures: – Availability – Enrollment – Benefit and payment provisions – Cost

MEPS-IC Sample Design Sample of private establishments drawn from the Census Bureau’s Business Register Sample of private establishments drawn from the Census Bureau’s Business Register – Approximately 42,000 establishments sampled Sample of state and local governments drawn from the Census Bureau’s Census of Governments Sample of state and local governments drawn from the Census Bureau’s Census of Governments – Approximately 2,000 governmental units sampled (No longer collected) Sample of employers directly linked to the MEPS Household Survey (No longer collected) Sample of employers directly linked to the MEPS Household Survey – Last year available is 2001

MEPS-IC Sample Design Designed to make National, State, and some Metro area estimates Designed to make National, State, and some Metro area estimates Designed to make year-to-year estimates Designed to make year-to-year estimates Data is Census Bureau Confidential - Public Use Files are not available Data is Census Bureau Confidential - Public Use Files are not available Methodology Reports available on website Methodology Reports available on website

Types of Information Collected Establishment-level (location) characteristics Establishment-level (location) characteristics Health insurance plan characteristics Health insurance plan characteristics Firm-level (company) characteristics Firm-level (company) characteristics

Medical Expenditure Panel Survey Medical Conditions

MEPS Condition Roster One roster per person One roster per person Cumulates medical conditions reported across MEPS interviews Cumulates medical conditions reported across MEPS interviews Source of conditions Source of conditions – Following 4 sections: Condition Enumeration Condition Enumeration Priority Conditions Priority Conditions Medical Events Medical Events Disability Disability

General File Structure Each record represents a unique condition or procedure reported by a household respondent Each record represents a unique condition or procedure reported by a household respondent Depending on the number of conditions reported, persons may be represented on the file Depending on the number of conditions reported, persons may be represented on the file – once – several times – not at all

Condition Enumeration We're interested in learning about health problems that may have bothered (PERSON) {since (START DATE)/between (START DATE) and (END DATE)}. We're interested in learning about health problems that may have bothered (PERSON) {since (START DATE)/between (START DATE) and (END DATE)}. – Health problems include physical conditions, accidents, or injuries that affect any part of the body as well as mental or emotional health conditions, such as feeling sad, blue, or anxious about something.

Condition Enumeration Asked in every round Asked in every round Has a time frame (since last interview until today) Has a time frame (since last interview until today) – Responses recorded verbatim and coded into 5 digit ICD9 codes – Responses directly linked to conditions roster – Chronic/priority conditions appear only once on the roster – Acute conditions can have many records – Responses aggregated across rounds for the annual responses

Priority Conditions New section since Panel 12 New section since Panel 12 Separate section of questionnaire Separate section of questionnaire Series of questions asking if “ever” had condition Series of questions asking if “ever” had condition – “yes/no” responses, no ICD9 coding – responses of “yes” with a current utilization record will appear on person’s condition roster Factors used in determining priority conditions Factors used in determining priority conditions – Prevalence – Expenditures – Policy relevance

Priority Conditions List Priority Conditions List Heart disease Heart disease Heart attack Heart attack Angina Angina High cholesterol High cholesterol Cancer Cancer Stroke Stroke High blood pressure High blood pressure Diabetes Diabetes Asthma Asthma Arthritis/Joint pain Arthritis/Joint pain Emphysema Emphysema Chronic bronchitis Chronic bronchitis Attention deficit disorder Attention deficit disorder

Medical Events What conditions were discovered or led (PERSON) to make this visit? PROBE: Any other condition? IF CONDITION IS ALREADY LISTED, ASK: Is this the same (NAME OF CONDITION) that we have already talked about before? What conditions were discovered or led (PERSON) to make this visit? PROBE: Any other condition? IF CONDITION IS ALREADY LISTED, ASK: Is this the same (NAME OF CONDITION) that we have already talked about before? – Types of visits Inpatient Inpatient Outpatient Outpatient Emergency Room Emergency Room Office Based Office Based Home Health Home Health Conditions associated with Prescribed Medicine purchases: Conditions associated with Prescribed Medicine purchases: – What health problem is (MEDICINE) prescribed for? PROBE: Any other health problems?

Disability Days Missed school or work Missed school or work – What are the health problems that caused (PERSON) to miss work/school on those days? PROBE: Any other health problems? Bed days Bed days – What are the health problems that caused (PERSON) to spend half day or more in bed on those days? PROBE: Any other health problems?

Reporting and Recording Conditions Respondents may report having the same condition more than once Respondents may report having the same condition more than once – Interviewer verifies that these are different occurrences of the condition – each unique episode of a condition is recorded only once person may have more than one cold in a year person may have more than one cold in a year each cold has a separate record each cold has a separate record

Condition Coding Coding and Editing Coding and Editing – Text strings coded into fully specified ICD-9 CM codes (up to 5 digits) – Collapsed into 3 digits to maintain confidentiality – Approximately 10% of condition codes are collapsed further by combining 2 or more 3-digit codes Clinical Classification System (CCS codes) - ICD-9 codes aggregated into clinically meaningful categories Clinical Classification System (CCS codes) - ICD-9 codes aggregated into clinically meaningful categories Limitations: clustering of ICD-9 codes in NEC (not elsewhere classified) and one respondent provides information for the entire household Limitations: clustering of ICD-9 codes in NEC (not elsewhere classified) and one respondent provides information for the entire household

Medical Expenditure Panel Survey Health Care Utilization and Expenditures

Health Care Utilization MEPS household respondents asked to report all health care use for family members during reference period MEPS household respondents asked to report all health care use for family members during reference period Utilization is called an “event” in MEPS Utilization is called an “event” in MEPS Event type categories: Event type categories: – Office-Based Medical Provider Visits (OB) – Hospital Inpatient Stays (IP) – Outpatient Department Visits (OP) – Emergency Room Visits (ER) – Dental Visits (DN) – Prescription Medicine Purchases (RX) – Home Health Care (HH) – Other Medical Expenses (OM)

Health Care Expenditures Collected at the event level Collected at the event level Represent payments to providers of the health care Represent payments to providers of the health care Payments are reported by source (e.g., out-of-pocket, private insurance, public program) Payments are reported by source (e.g., out-of-pocket, private insurance, public program) Total expenditure is the sum of payments across all sources of payment Total expenditure is the sum of payments across all sources of payment

Source of Payment Categories Self or family Self or family Medicare Medicare Medicaid Medicaid Private insurance Private insurance VA VA TRICARE TRICARE Other federal gov’t Other federal gov’t State or local gov’t State or local gov’t Worker’s comp Worker’s comp Other insurance Other insurance

Sources of Expenditure Data Expenditures derived from two survey components: Expenditures derived from two survey components: – Household Component (HC) – Medical Provider Component (MPC) MPC data used to replace and/or supplement household-reported expenditures MPC data used to replace and/or supplement household-reported expenditures Incomplete data on expenditures for an event is imputed - no missing values Incomplete data on expenditures for an event is imputed - no missing values

Sources of Expenditure Data by Event Type Event type HCMPC OB: Physician yesyes OB: Non-Physician yesno IPyesyes OPyesyes ERyesyes DNyesno RXnoyes HH: Agency noyes HH: Paid independent yesno OMyesno

Annual Expenditure Data Annual data cumulated across approx 2 ½ rounds of data collection Annual data cumulated across approx 2 ½ rounds of data collection Event level files Event level files – Separate by type of service – Unique record for each reported event Some persons have no events Some persons have no events Some persons have multiple events Some persons have multiple events Person-level file (full year consolidated) Person-level file (full year consolidated) Variables derived from event level Variables derived from event level

Event Level File Record Units EVENT TYPE RECORD UNIT OBvisit OPvisit ERvisit IPstay DNvisit HHmonth RX original script or refill original script or refill

Flat Fees What is a Flat Fee? What is a Flat Fee? – A fixed dollar amount paid for a group of health care services – Common examples: orthodontic, prenatal care Flat Fee ID: FFEEIDX Flat Fee ID: FFEEIDX Flat fee structure (FFevTYPE) Flat fee structure (FFevTYPE) – Stem - Initial medical visit - expenditures – Leaf - subsequent medical visits - zero expenditures

Zero Dollar Events Reasons for $0 total expenditures Reasons for $0 total expenditures – Leaf event in flat fee bundle from prior year – Follow-up visit without extra charge – Free care – Bad debt

Medical Expenditure Panel Survey DISSEMINATION OF INFORMATION AND DATA PRODUCTS

MEPS Website Overview of MEPS and Frequently Asked Questions (FAQs) Overview of MEPS and Frequently Asked Questions (FAQs) Staff Reports using MEPS Staff Reports using MEPS Findings/Statistical Briefs/Chart books Findings/Statistical Briefs/Chart books Data Tables of Estimates Data Tables of Estimates Public Use Files (microdata) Public Use Files (microdata) MEPSnet Interactive Query Tool MEPSnet Interactive Query Tool Survey Methodology Reports Survey Methodology Reports Survey Questionnaires and Other Collection Materials Survey Questionnaires and Other Collection Materials Data product availability and ordering information Data product availability and ordering information MEPS data workshop information and schedule MEPS data workshop information and schedule Mailing list, List server and for technical assistance Mailing list, List server and for technical assistance Data Center Information Data Center Information

Data User Workshops Information will be posted on Workshops and Events section of web site Information will be posted on Workshops and Events section of web site For inquiries please For inquiries please

MEPS Publications Statistical Briefs: Easy-to-read, concise graphical summaries of MEPS data Statistical Briefs: Easy-to-read, concise graphical summaries of MEPS data Research Findings and Highlights: Tables and summaries of descriptive statistics Research Findings and Highlights: Tables and summaries of descriptive statistics Methodology Reports: Detailed information on MEPS sample design and survey methods Methodology Reports: Detailed information on MEPS sample design and survey methods Chartbooks: Policy-sensitive topics in an accessible question-and-answer format Chartbooks: Policy-sensitive topics in an accessible question-and-answer format Working Papers: Preliminary analyses of methodological and technical issues by AHRQ staff Working Papers: Preliminary analyses of methodological and technical issues by AHRQ staff Research in Action: Analyses using research results from AHRQ-sponsored studies, including MEPS data Research in Action: Analyses using research results from AHRQ-sponsored studies, including MEPS data

Micro Data Files Public Use Files (Microdata) – Available for downloading from web site (Household survey only) Public Use Files (Microdata) – Available for downloading from web site (Household survey only) Restricted Access Files (Microdata) Restricted Access Files (Microdata) – MEPS-HC – Available for Use at AHRQ Data Center – MEPS-IC – Available for Use at Census Research Data Centers For more information go to

Contact Information MEPS address - MEPS address - MEPS Information Coordinator: MEPS Information Coordinator: – (301)

AHRQ Data Center Provides researchers access to non-public use MEPS data (except directly identifiable information) Provides researchers access to non-public use MEPS data (except directly identifiable information) Located in Rockville, MD Located in Rockville, MD Applications/procedures on MEPS web site Applications/procedures on MEPS web site User fee of $ includes up to 2 hours of programming (fee waived for full-time students) User fee of $ includes up to 2 hours of programming (fee waived for full-time students)

AHRQ Data Center Facilities Secure room Secure room Terminal connected to secure LAN Terminal connected to secure LAN SAS, STATA, GAUSS, Stat Transfer, SUDAAN, Limdep, EQS software available, and others upon request SAS, STATA, GAUSS, Stat Transfer, SUDAAN, Limdep, EQS software available, and others upon request Limited staff support by people who know: Limited staff support by people who know: – the data – the confidentiality issues – the software

ADC Guidelines Researcher may bring data in, but not out Researcher may bring data in, but not out Researcher has access only to data needed for approved project Researcher has access only to data needed for approved project All tabular data will be reviewed for confidentiality before release from Center All tabular data will be reviewed for confidentiality before release from Center Only approved tables can leave the Center Only approved tables can leave the Center Center will store data files, foreign merge files, and all outputs needed for replication Center will store data files, foreign merge files, and all outputs needed for replication

ADC Limited Remote Access Once you have an established data center project, and have worked on site to develop and debug programs, jobs may be submitted to our Data Center Supervisor to run. Output will be reviewed for confidentiality and mailed to you. Once you have an established data center project, and have worked on site to develop and debug programs, jobs may be submitted to our Data Center Supervisor to run. Output will be reviewed for confidentiality and mailed to you.

ADC Application Procedures Application procedures are on the MEPS web site Application procedures are on the MEPS web site Submit proposal to data center coordinator Submit proposal to data center coordinator Review within 1 week for feasibility, and data availability Review within 1 week for feasibility, and data availability Institutional Review Board (IRB) review required Institutional Review Board (IRB) review required

Data Center Questions Contact Data Center Administrator by at: Contact Data Center Administrator by at:

Census Bureau Research Data Centers (RDC) Access to MEPS-IC data files and other files (including MEPS- HC) Access to MEPS-IC data files and other files (including MEPS- HC) All work takes place at a RDC operated by the Census Bureau’s Center for Economic Studies All work takes place at a RDC operated by the Census Bureau’s Center for Economic Studies – University of Washington (coming Summer 2012) – Texas (coming Fall 2012) – Atlanta (Federal Reserve Bank) – Boston (NBER) – UC-Berkeley – UCLA – Stanford – Washington DC (Census HQ) – Chicago (Federal Reserve Bank) – University of Michigan – University of Minnesota – Baruch School of Public Affairs (New York City) – Cornell University – Duke University – Research Triangle (RTI)

Medical Expenditure Panel Survey MEPS Web Analytical Tools

The MEPS web site contains two web analytical tools: MEPSnet Query Tools MEPSnet Query Tools Customizable Summary Data Tables Customizable Summary Data Tables

MEPSnet Query Tools MEPSnet is a collection of analytical tools offering online capability to generate MEPS estimates. The tools are divided into two sections: MEPSnet/Household Component MEPSnet/HC MEPSnet/Household Component MEPSnet/HC MEPSnet/Insurance Component MEPSnet/IC MEPSnet/Insurance Component MEPSnet/IC

Customizable Summary Data Tables The following MEPS Summary Data Tables are customizable: All of the Expenditures by Health Care Service Tables All of the Expenditures by Health Care Service Tables All of the Expenditures by Medical Condition Tables All of the Expenditures by Medical Condition Tables All of the Quality of Care Tables All of the Quality of Care Tables Only Table 1, Usual Source of Health Care and Only Table 1, Usual Source of Health Care and Selected Population Characteristics, United States Selected Population Characteristics, United States from the Access to Care Tables from the Access to Care Tables

Medical Expenditure Panel Survey Considerations for Developing an Analytical File

Major Areas of Health Research Topics Using MEPS Data Access Use Expenditures Health insurance Health status and conditions Quality First order of business is to define goals of analysis using MEPS data as clearly as possible!

Sources of Useful Information MEPS-HC Questionnaires Public Use File Documentation – General information about MEPS – File-specific general information – File specific variable information Person-level or Family-level Condition-level or Event-level MEPS supplement questions Public Use File Codebooks – Good source of overview information – Formatted frequencies for all variables on file Both weighted and unweighted

Variable Naming Conventions Edited Variables end in an “X” – For example: RACEX Names of year specific variables use last two digits of year – For example: TOTEXP09, PERWT09F, AGE09X For round specific variables, round designation is indicated at the end of the variable or immediately before the “X” in the case of edited variables – For example: AGE31X, AGE42X, AGE53X – Certain questions or instrument sections are only asked in certain rounds, e.g. the Self-Administered Questionnaire in rounds 2 and 4

General Tips Clearly define research objectives Read the documentation Subset to only the variables you need for your analysis Do not subset to specific populations prior to running statistical analyses Compare program output with codebooks Use the correct weight, stratum and psu variables (including supplement weights) Read the documentation!