1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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]

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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)

16. 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.

17. General Priority of MEPS Expenditure Data Source2 1
Household
Component
(HC)
Medical Provider Component
(MPC)
Utilization
Expenditure Data
Expenditure Data
Imputation (maximize use of MPC data as donors) 3

18. 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)

19. 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

20. 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%

21. Research Uses of the Medical Expenditure Panel Survey

22. 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

23. 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

24. Expenditures by Event Type

25. Expenditures by Source of Payment

26. 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

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

28. 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

29. 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

30. Total person level prescribed medicine expenditures for persons with prescribed medicine fills,
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,

31. 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,

32. 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.

33. Percentage of Nonelderly Adults with Employer-Sponsored Insurance Facing Health Care Burden Exceeding 20 Percent of Family Income, by Income and Deductible Level,
SOURCE Abdus et al., 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.

34. 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

35. Contact Information
Steve Machlin:
Joel Cohen:
MEPS Website