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National Healthcare Disparities Report, 2003

Medicare Current Beneficiary Survey (MCBS)

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Overview of MCBS

The Medicare Current Beneficiary Survey (MCBS) is conducted by the Office of Strategic Planning of the Centers for Medicare & Medicaid Services (CMS). It is a continuous, multipurpose survey of a nationally representative sample of the Medicare population, providing information on aged and disabled Medicare beneficiaries living in communities and long-term care facilities. The sample is selected from Medicare enrollment files, and sample persons are interviewed three times per year over a four-year period. Sample data are collected through computer-assisted personal interviews of the beneficiary or a proxy respondent if the sample person is not available for the interview. Survey questionnaires are tailored to the residence of the sample person' community or long-term care facility. If the sample person moves from one setting to the other during the period covered by an interview, a separate interview is administered for the time spent in each setting. As a consequence, beneficiaries are followed continuously over time regardless of where they live.

The primary goal of the survey is to collect comprehensive information on all medical services used by Medicare beneficiaries, sources of payment, health insurance coverage, and socioeconomic and demographic characteristics of the population. These data are used by the Office of Strategic Planning and the Office of the Actuary to support a host of activities related to the administration of the Medicare Program (health insurance for the aged and disabled) and the Medicaid Program (federal grants to states for medical assistance programs). CMS also uses the data to evaluate the Medicare and Medicaid programs and to assess the financial impact of programmatic change on beneficiaries and the Medicare trust fund.

Two public use files (PUFs) are created for each calendar year of data collected in the MCBS: Access to Care and Cost and Use. Access to Care files are made available to the public about one year after the close of field work for the fall interview period (September-December). These PUFs contain the "always enrolled" segment of the Medicare population; i.e., individuals who were enrolled in Medicare Part A or Part B as of January 1 of the year of data collection and alive at the time of the fall interview. They exclude beneficiaries who enrolled in Medicare during the year, and beneficiaries who died before they could be interviewed in the fall round.

Access to Care files contain a mix of Medicare program data from administrative file and survey data from the fall round of interviews. The program data include summaries of Medicare-covered health care use and expenditures for the year. The survey-reported data include information from the fall round of interviews on health insurance coverage, health status and functioning, and access to and satisfaction with care. These PUFs are most appropriate for users interested in analyzing the continuously enrolled population and its use of Medicare-covered services. The files also contain longitudinal weights that can be used to track cohorts of Medicare beneficiaries over time (two, three or four years).

Cost and Use files are released about two years after the close of field work for the calendar year. They contain a nationally representative sample of "ever enrolled" Medicare beneficiaries, i.e., all persons who were in the program at any time during the calendar year. The data include survey-reported information on health care use, Medicare claims data for unreported services, and administrative data such as Medicaid buy-in status and Medicare managed care plan enrollment.

Health care expenditures in the Cost and Use files are created through an elaborate set of procedures to reconcile Medicare claims data and survey-reported events and to impute for missing information on sources and amounts of payment. As a result, Cost and Use files provide a more comprehensive picture of health care expenditures by Medicare enrollees than would be available from either the administrative data or the survey-reported events. They contain information on all services used by Medicare beneficiaries during the year including health care not covered by Medicare, and the sample is representative of the entire Medicare population. These files are most appropriate for analyses requiring all Medicare beneficiaries or expenditures on all types of health care.

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MCBS Files Used for the NHDR

MCBS data for the National Healthcare Disparities Report (NHDR) are primarily drawn from the 1999 Cost and Use file. The Cost and Use file was chosen over the Access to Care file as the primary source of data on Medicare beneficiaries for three reasons. First, it contains a nationally representative sample of all Medicare beneficiaries rather than just the always enrolled population. Second, it has information on health care expenditures not included in the Access to Care files (e.g., non-covered services such as dental and vision care and prescribed medicines). Third, information on beneficiary income is complete and continuous for each sample person in the Cost and Use file, as opposed to incomplete and categorical in the Access to Care file.

However, the Cost and Use file could not be used independently of the Access to Care file to produce all of the statistics requested for the NHDR. It lacks information collected in the fall round on satisfaction with care, access to care and usual source of care. This deficiency was corrected by appending the needed data from the 1999 Access to Care file to sample persons in the Cost and Use file. Then the augmented Cost and Use file was used to generate statistics on elderly (age 65 or older) beneficiaries who lived in community settings. All beneficiaries under the age of 65 and elderly beneficiaries who spent any time in long-term care facilities were excluded from MCBS tabulations for the NHDR.

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MCBS Table Notes

MCBS Sample for NHDR

The sample used to generate statistics on elderly Medicare beneficiaries living in community settings in 1999 contains 9,996 persons. They represent 32,692,000 Medicare beneficiaries, or approximately three-quarters of all persons enrolled in Medicare Part A or Part B in 1999. The distribution of this sample, by gender and age, is shown below:

NHDR Sample Unweighted Weighted
Gender    
Male 4,253 14,008,000
Female 5,743 18,683,000
Age    
65 to 74 4,652 17,490,000
75 to 84 3,887 11,790,000
85 and older 1,457 3,412,000

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Contrast (Column) Variables

MCBS tables on access, use and quality were created with standardized column headings for race, ethnicity, and poverty status. The MCBS race and ethnicity variables are coded from beneficiary responses to the survey questions, and the categories are recorded as interpreted by the respondent. Race categories include American Indian, Asian or Pacific Islander, black or African American, white, more than one race, or other race. Hispanic ethnicity categories include persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. Distributions, by race and ethnicity, are shown below:

NHDR Sample Unweighted Weighted
Race    
White 8,656 28,478,000
Black 886 2,622,000
American Indian 55 202,000
Asian/Pacific Islander 205 751,000
Other 194 640,000
Ethnicity    
Non-hispanic white 8,135 26,775,000
Non-hispanic black 854 2,516,000
Non-hispanic other 337 1,209,000
Hispanic 1,858 2,142,000

Poverty status categories were created for sample persons in the survey based on their reported or imputed income from all sources. Each person was assigned to a poverty status category by using US Bureau of the Census data on poverty thresholds in 1999, by size of family and number of related children under 18 years. The constructed variables are based on the assumption that not married beneficiaries were one person families and married beneficiaries were two person families. For beneficiaries age 65 or older, the 1999 poverty thresholds were $7,990 for not married beneficiaries and $10,075 for married beneficiaries. The distribution of beneficiaries by poverty status is shown in the following table:

NHDR Sample Unweighted Weighted
Poverty Status    
Below Threshold 1,520 4,665,000
1-2 times Threshold 3,331 18,683,000
2-4 times Threshold 3,277 10,977,000
4+ times Threshold 1,858 6,599,000

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Other (Row) Variables

Age

Three age categories were developed for the NHDR tables on elderly community residents: 65 to 74, 75 to 84, and 85 and older. Each sample person was assigned to a category based on his or her age as of July 1, 1999.

Gender

Gender is recorded as reported on the Medicare/Social Security administrative record for the sample person.

Insurance Coverage

Insurance coverage in the MCBS is based on a combination of Medicare and Medicaid administrative data and survey-reported information on public and private insurance. The information is used to construct month-by-month timelines of coverage by type of insurance for each sample person in a Cost and Use file. In addition, summary health insurance variables are created by using the month-by-month variables to identify persons who had a particular type of insurance at any time in the year.

The types of insurance identified in the MCBS include Medicare fee-for-service, Medicare managed care, Medicaid, private employer-sponsored, private individually purchased (Medigap), private health maintenance organization, and other insurance. Summary versions of these variables were used to create four mutually exclusive groups of Medicare beneficiaries by prioritizing insurance coverage as follows:

  • Group 1 contains everyone who had Medicaid regardless of other coverage.
  • Group 2 contains persons in Medicare managed care plans regardless of other coverage.
  • Group 3 contains persons with private insurance (Medigap, employer-sponsored or HMO).
  • Group 4 contains all remaining beneficiaries, i.e., Medicare fee-for-service beneficiaries who did not have Medicaid or private insurance.

Urban/rural

Sample persons are classified as living in a metropolitan or non-metropolitan area based on their addresses in the Medicare administrative files.

Perceived Health Status

Each sample person in the MCBS is asked to compare his or her general health to other persons of the same age. Persons receiving a community interview answer the question themselves. If a sample person is not able to do so, the proxy for that person answers the question. The possible responses to the question include excellent, very good, good, fair, and poor. Persons reporting fair or poor health are shown in the NHDR tables.

Functional Limitations

Sample persons are identified as having functional limitations through their responses to six sets of questions about activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Sample persons are asked whether they have a health or physical problem that makes it difficult to perform any of the specified activities. If the response is yes, they are recorded as having a limitation in that particular activity. If the response is "doesn't do," they are asked whether it is because of a health or physical problem. Then, if the response to the follow-up question is "yes," they are recorded as having a limitation in that particular activity.

The ADLs are activities related to personal care; and, they include bathing or showering, dressing, eating, getting in or out of bed or a chair, walking, and toileting. The IADLs are activities related to independent living; and, they include using the telephone, doing light housework, doing heavy housework, preparing meals, shopping for personal items, and managing money. Any limitation reported by a sample person may have been temporary or chronic at the time of the interview.

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Types of Data

The standardized table shells were used to compare and contrast information on selected measures of access, use and expenditures, and quality of care for elderly persons living in communities. The measures and methods used to construct them are described below:

Expenditure Tables

The MCBS Cost and Use files contain charge and payment information for each service received by a sample person. The charge is the amount to which a provider was legally entitled to collect for the service, and it is equal to the sum of payments from eleven potential payers. One of the eleven potential payers is "amount discount," which is used to account for any difference between the allowed charge and payments from the other ten sources. Assume, for example, a provider was entitled to $100 for an office consultation and the sum of payments from the patient and third party payers such as Medicare, Medicaid, and private insurance was $90. The remaining $10 to which the provider was entitled would be considered uncollected liability and assigned to "amount discount" to make the sum of payments by the eleven sources equal the allowed charge.

Total expenditures in tables prepared for the NHDR are defined as the sum of payments from all sources except amount discount. The payments represent the amounts received by providers for their services. The ten sources from which a provider might receive payment include Medicare, Medicaid, Medicare HMO, private HMO, Veterans Administration, employer-sponsored private insurance, individually purchased private insurance, private insurance from an unknown source, the sample person, and public health plans other than Medicare or Medicaid.

Two sets of tables were created to compare and contrast mean outlays for all services and for prescription drug purchases by elderly community residents. One set includes all of the elderly community residents in the sample (per capita expenditure tables). The other set includes only the elderly community residents with expenditures (per user expenditure tables).

User Rate Tables

User rate tables were created to compare and contrast the proportion of beneficiaries with expenditures for inpatient hospital services and for prescription medicine purchases. Separate tables were created for inpatient hospital services and for prescription drug purchases. Users are defined as persons with an expense for at least one of the relevant services, and user rates are calculated as the proportion of persons with an expense in each cell in the standardized tables.

Source of Payment Tables

Two sets of tables were created to show the proportion of expenses paid out-of-pocket for all services and for prescription medicines. The out-of-pocket share of total expenditures in these tables is defined as the sum of out-of-pocket payments by all persons in a cell divided by their total expenditures.

Access and Satisfaction Tables

Six sets of tables were created to assess dimensions of access to and satisfaction with health care by elderly community residents. The tables are based on responses to the following questions about medical care received in the year preceding the interview:

  • The "Usual Source of Care" tables show the proportion of persons who did not have access to a particular medical person or clinic when they were sick or needed medical advice.
  • The "Had Trouble Getting Care" tables show the proportion of persons who reported difficulty getting care that they wanted or needed.
  • The "Delayed Care Due to Cost" tables show the proportion of persons who reported that they delayed seeking care because they were worried about the cost.
  • The "Quality of Care" tables show the proportion of persons who were dissatisfied or very dissatisfied with the overall quality of care received during the previous twelve months.
  • The "Availability of Care" tables show the proportion of persons who were dissatisfied or very dissatisfied with the availability of care at night and on weekends.
  • The "Ease of Getting to a Doctor" tables show the proportion of persons who were dissatisfied or very dissatisfied with the ease and convenience of getting to a doctor from their residence.

All of the tables show the proportion of negative responses by persons within a cell. The denominator for the proportions includes the total population of the cell regardless of how the sample person responded to the question. For questions concerning satisfaction with care, the denominator for a cell may include persons who reported no experience with the dimension of health care about which the question asked.

Computation of Statistics and Standard Errors

The counts, means, and proportions in the tables are weighted to reflect the "ever enrolled" Medicare population in 1999. In addition, standard errors are included in the tables in order to assess the impact of sampling variability on the accuracy of the estimates. They were estimated by using a software package (SUDAAN) that accounts for the impact of non-random sampling procedures on the precision of the weighted estimates.

Not all table cells have a value. If a cell had fewer than 30 observations or the relative standard error of the estimate was greater than 30, the value for that cell was suppressed. This rule was implemented to avoid reporting statistically unreliable estimates of the characteristics of elderly community residents.

Return to Appendix B: Methods
2003 National Healthcare Disparities Report

 

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