National Healthcare Quality & National Healthcare Disparities Reports: Detailed Methods Appendix, 2013
The Medical Expenditure Panel Survey (MEPS) is designed to provide nationally representative estimates of health care use, expenditures, sources of payment, and insurance coverage for the U.S. civilian noninstitutionalized population. MEPS is cosponsored by the Agency for Healthcare Research and Quality (AHRQ) and the National Center for Health Statistics (NCHS). MEPS comprises three component surveys: the Household Component (HC), the Medical Provider Component (MPC), and the Insurance Component (IC). The HC is the core survey of MEPS.
The MEPS HC, a nationally representative survey of the U.S. civilian noninstitutionalized population, collects medical expenditure data at both the person and household levels. The HC collects detailed data on demographic characteristics, health conditions, health status including adult disability status as measured by activity limitations, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment.
The HC uses an overlapping panel design in which data are collected through a preliminary contact followed by a series of five rounds of interviews over a 2½-year period. Through the use of computer-assisted personal interviewing technology, data on medical expenditures and use for 2 calendar years are collected from each household. This series of data collection rounds is launched each year on a new sample of households to provide overlapping panels of survey data and, when combined with other ongoing panels, will provide continuous and current estimates of health care expenditures.
The sample of households selected for the MEPS HC is drawn from respondents to the National Health Interview Survey (NHIS), conducted by NCHS. NHIS provides a nationally representative sample of the U.S. civilian noninstitutionalized population, with oversampling of Hispanics and Blacks. Each new MEPS panel includes some oversampling of population groups of particular analytic interest. For the panel that began in 2011 (Panel 16) the following two domains were oversampled in addition to Asians, Blacks, and Hispanics: DUs with one or more persons reporting a cancer diagnosis in the 2010 NHIS were selected with certainty; the second new domain was created by dividing what in prior years had been a single domain, the 'white/other' domain, into two domains, one consisting of NHIS 'partial completes', the other of NHIS 'completes'. The 'partial completes' were sampled at a lower rate than the 'completes'.
For more detailed information about MEPS and the information discussed here, refer to documentation for the MEPS 2002-2011 Full Year Consolidated Data Files, available at http://www.meps.ahrq.gov.
National health care estimates from MEPS for the 2013 NHQR and NHDR were derived from the 2002-2010 MEPS HC survey, including the Self-Administered Questionnaire (SAQ), the Child Health and Preventive Care section, and the Diabetes Care Survey (DCS). The access to care estimates included in the report were derived from the Access to Care (AC) section of the 2011 MEPS HC survey. Data were collected as indicated below:
- 2002: rounds 3, 4, and 5 of panel 6 and rounds 1, 2, and 3 of panel 7.
- 2003: rounds 3, 4, and 5 of panel 7 and rounds 1, 2, and 3 of panel 8.
- 2004: rounds 3, 4, and 5 of panel 8 and rounds 1, 2, and 3 of panel 9.
- 2005: rounds 3, 4, and 5 of panel 9 and rounds 1, 2, and 3 of panel 10.
- 2006: rounds 3, 4, and 5 of panel 10 and rounds 1, 2, and 3 of panel 11.
- 2007: rounds 3, 4, and 5 of panel 11 and rounds 1, 2, and 3 of panel 12.
- 2008: rounds 3, 4, and 5 of panel 12 and rounds 1, 2, and 3 of panel 13.
- 2009: rounds 3, 4, and 5 of panel 13 and rounds 1, 2, and 3 of panel 14.
- 2010: rounds 3, 4, and 5 of panel 14 and rounds 1, 2, and 3 of panel 15.
The SAQ is a supplement to the MEPS HC that includes health care quality measures taken from the health plan version of CAHPS® (Consumer Assessment of Healthcare Providers and Systems), an AHRQ-sponsored family of survey instruments designed to measure quality of care from the consumer's perspective; general health questions; attitudes about health questions; and health status questions as measured by the SF-12 and the EuroQol 5D.
The Child Health and Preventive Care section is part of the regular MEPS HC interview. It includes health care quality measures taken from the health plan version of CAHPS®; Children with Special Health Care Needs (CSHCN) Screener questions; children's general health status as measured by several questions from the General Health Subscale of the Child Health Questionnaire; Columbia Impairment Scale questions about possible child behavioral problems; and child preventive care questions. Researchers should note that the CAHPS® and CSHCN questions changed from a self-administered parent questionnaire in 2000 to an interviewer-administered questionnaire starting in 2001.
A third supplement to the MEPS HC, the DCS, is a self-administered questionnaire given to people identified with diabetes. It questions respondents about the care they received in the treatment of their diabetes.
Estimates derived from MEPS are presented at both an aggregate level and for select subpopulations. Characteristics used to define subpopulations include age, gender, race, ethnicity, poverty status, education, insurance coverage, residence location, , employment status, perceived health status, children with special health care needs, language spoken most often at home, usual primary care provider, CAHPS® composite measure, adults age 65 and over who received potentially inappropriate prescription medications in the calendar year, adult disability status as measured by activity limitations, whether U.S. born, financial burden of health care costs, and underinsurance. A brief description of how each of these population characteristics was defined is provided below.
Age—With the exception of analytic variables associated with round-specific questions noted below, age was defined as a person's age on December 31 of the data year.
For measures using analytic variables associated with round-specific questions (e.g., questions from the SAQ, the Child Health and Preventive Care supplement, and access-to-care measures), corresponding round-specific age variables were used to determine age.
Gender—Male or female.
Race—MEPS tables are shown starting with 2002 data, the year MEPS transitioned to the Office of Management and Budget (OMB) standards issued in 1997 for collecting racial and ethnic data. The new standards allow respondents to identify more than one racial group (http://www.whitehouse.gov/omb/fedreg_1997standards/). For all tables, race is classified into five single race categories and a multiple-race category, as follows: (1) White, (2) Black, (3) Asian, (4) Native Hawaiian or Other Pacific Islander, (5) American Indian or Alaska Native, and (6) multiple races. Because of differences in the classification of race, racial estimates reported using MEPS data from 2002 and subsequent years is not directly comparable with estimates that use data prior to 2002.
Ethnicity—Ethnicity was designated as either Hispanic or non-Hispanic. People of Hispanic origin may be of any race. Estimates were derived for both Hispanic and non-Hispanic subpopulations. In addition, race was combined with ethnicity to enable estimation of data for categories that include non-Hispanic White, non-Hispanic Black, and non-Hispanic other. For 2002 and later years, non-Hispanic White and non-Hispanic Black categories excluded multiple-race individuals; estimates are not directly comparable with data from previous years.
Poverty status—MEPS includes a five-level categorical variable for family income as a percentage of poverty. For construction of this variable, definitions of income, family, and poverty are taken from the poverty statistics developed by the Current Population Survey. For the purposes of analysis and reporting in the NHDR, the near-poor and low-income categories were combined. This resulted in a four-level categorical variable of poverty status: (1) negative or poor refers to household incomes below the Federal poverty level (FPL); (2) near poor/low income, from the FPL to just below 200 percent of the FPL; (3) middle income, 200 percent to just below 400 percent of the FPL; and (4) high income, 400 percent or more of the FPL.
Education—Reporting of educational attainment is based on the number of completed years of education when they first entered MEPS. For the NHQR and NHDR, this continuous measure was grouped into three categories: (1) less than high school refers to people with less than 12 completed years of education; (2) high school graduate, people with exactly 12 completed years of education; and (3)at least some college, people with greater than 12 completed years of education. This variable was constructed only for people age 18 years and over and any measure presented for the education subpopulations includes only people in this age group.
Insurance coverage—Insurance coverage was constructed in a hierarchical manner and in relation to a person's age. For the population under age 65, those who were uninsured for the entire year were classified as "uninsured"; those who had any private coverage at any time during the year (including TRICARE/CHAMPVA) were classified as having "private insurance"; and those who had only public coverage (i.e., no private) at any time during the year were classified as "public only". The population age 65 and over was classified as "Medicare only", "Medicare and private", or "Medicare and other public assistance". A small number of people age 65 and over were found to only have private insurance or to be uninsured. This residual group is not shown in the tables.
Residence location—The 2013 NHDR and NHQR use the 2006 NCHS Urban-Rural Classification Scheme for Counties. NCHS based this classification scheme for counties on the OMB definitions of metropolitan and nonmetropolitan counties; the Rural-Urban Continuum Codes and the Urban Influence Codes developed by the Economic Research Service of the U.S. Department of Agriculture; and county-level data from Census 2000 and 2004 postcensal population estimates. Urban-rural categories used in the 2013 NHQR and NHDR follow:
- Large central metro ("central" counties of metropolitan area of 1 million or more population).
- Large fringe metro ("fringe" counties of a metropolitan area of 1 million or more population).
- Medium metro (counties in metropolitan areas of 250,000 to 999,999 population).
- Small metro (counties in metropolitan areas of 50,000 to 249,999 population).
- Micropolitan (counties with at least one urban cluster of at least 10,000 residents).
- Noncore (counties without an urban cluster of at least 10,000 residents).
The two nonmetropolitan levels of the NCHS classification, micropolitan and noncore, are derived directly from the differentiation of nonmetropolitan territory specified in the 2003 OMB standards for defining metropolitan and micropolitan counties. For more information, visit http://www.cdc.gov/nchs/data_access/urban_rural.htm and http://www.ers.usda.gov/Briefing/Rurality/MicropolitanAreas/.
Employment status—MEPS includes four-level round-specific categorical variables for employment status for people age 16 years and over. For the MEPS tables, employment status variables were set for adults ages 18-64. For the NHDR and NHQR Employment status was grouped into two categories: Employed, which refers to adults who were (1) currently employed, (2) had a job to return to, or (3) had a job but did not work during the reference period; and not employed.
Perceived health status—MEPS includes five-level round-specific categorical variables for perceived health status; these categories include "excellent," "very good," "good," "fair," and "poor." For purposes of analyzing data in the NHQR and NHDR, these five levels were collapsed into two: (1) excellent, very good, or good; and (2) fair or poor.
Children with special health care needs—The Child Health and Preventive Care section identifies children with special health care needs (CSHCN) based on the CSHCN Screener instrument developed through a national collaborative process as part of the Child and Adolescent Health Measurement Initiative under the coordination of the Foundation for Accountability. Children whose "special health care needs" status could not be determined were coded as "unknown." Data for individuals classified as "unknown" are not shown in the NHDR and NHQR tables.
Language spoken most often at home—For each individual family member, the Access to Care section ascertained what language is spoken most often at home (LANGHM42), using the categories English, Spanish, and Other. These categories were collapsed into "English" and "Other."
Usual primary care provider—People are considered to have a usual primary care provider if they have a usual source of care not located in a hospital emergency room, to which they go for new health problems; preventive health care such as general checkups, examinations, and immunizations; and referrals to other professionals when needed.
CAHPS® composite measure (adults and children)—This measure identified people who had a doctor's office or clinic visit in the last 12 months whose health providers listened carefully, explained things clearly, showed respect for what they had to say, and spent enough time with them. For adults (children) who had a doctor's office or clinic visit in the last 12 months, percent distribution of how often the response categories of Always, Usually, and Sometimes or Never were selected for the four CAHPS questions asking about health providers: (1) listening carefully; (2) explaining things clearly; (3) showing respect for what they had to say; and (4) spending enough time with them. For example, if a person had responded "Always" for each of the four questions, the composite measure would be 100% for Always, 0% for Usually, and 0% for Sometimes or Never. If a person did not complete all four questions, the percentage estimates were weighted by the percentage of the four questions that they completed.
Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year—Prescription medications received includes all prescribed medications initially purchased or otherwise obtained during the calendar year, as well as any refills. Inappropriate medications are defined by the implementation of the Beers criteria1 in MEPS. According to this definition, the 11 drugs that should always be avoided for older patients include barbiturates, flurazepam, meprobamate, chlorpropamide, meperidine, pentazocine, trimethobenzamide, bellodonna alkaloids, dicyclomine, hyoscyamine, and propantheline. The 22 drugs that should often be avoided for older patients include carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, amitriptyline, chlordiazepoxide, diazepam, doxepin, indomethacin, dipyridamole, ticlopidine, methyldopa, reserpine, disopyramide, oxybutynin, chlorpheniramine, cyproheptadine, diphenhydramine, hydroxyzine, promethazine, and propoxyphene.
Adult disability status as measured by activity limitations—The NHQR and NHDR define adults with disabilities as those with physical, sensory, and/or mental health conditions that can be associated with a decrease in functioning in such day-to-day activities as bathing, walking, doing everyday chores, and/or engaging in work or social activities. Two measures are used in displaying disability data for adults. The first measure, limitations in basic activities, represents problems with mobility and other basic functioning at the person level. The second measure, limitations in complex activities, represents limitations encountered when the person, in interaction with his or her environment, attempts to participate in community life. Limitations in Basic activities include problems with mobility; self-care (activities of daily living); domestic life (instrumental activities of daily living); and activities dependent on sensory functioning (limited to people who are blind or deaf). Limitations in Complex activities include limitations experienced in work; and in community, social, and civic life. These two categories are not mutually exclusive; people may have limitations in basic activities and in complex activities. The residual category neither includes adults with neither basic nor complex activity limitations.
Whether U.S. born—The Access to Care section ascertains whether a person was born in the United States. This question was previously asked only if a language other than English was spoken in the home and only of those persons uncomfortable speaking English. Beginning in 2007, the question is asked of all RU members regardless of the language most often spoken in the home and regardless of whether all household members are comfortable speaking English. As a result, only data beginning in 2007 are shown in the NHDR and NHQR tables.
Financial burden of health care costs and underinsurance—Financial burden of health care costs and underinsurance are defined for people under age 65. Financial burden of health care costs is defined when a person's family level out-of-pocket health insurance premiums and medical expenditures are greater than 10 percent of total family income. Underinsurance is defined for people with private insurance when a person's family level out-of-pocket medical expenditures (excluding premiums) are greater than 10 percent of total family income.
The following family level variables are defined for these measures:
Family. The definition of family is based on the MEPS health insurance eligibility unit (HIEU), which includes all members of the family who would typically be covered under a private insurance family plan. HIEUs include adults, their spouses, and their unmarried natural/adoptive children under age 18 and children under age 24 who are full-time students.
Nonelderly families include families in which at least one person is under age 65. In these cases, family-level expenditures include the expenditures for the elderly person as well. Elderly families in which all persons are age 65 years or above are not included in this analysis.
Out-of-pocket expenditures on health care services. Out-of-pocket expenses include all out-of-pocket payments for deductibles, coinsurance, copayments, and payments for any noncovered services and supplies. Using the HIEU definition of family unit, we add out-of-pocket expenditures on health care services across all members of the family to calculate family-level out-of-pocket expenditures on health care services.
Out-of-pocket expenditures on health insurance premiums. MEPS collects out-of-pocket expenditures on premiums for private health insurance from household respondents. We add private out-of-pocket premium costs and (imputed) Medicare Part B premiums across all health insurance policies covering family members. For example, if there are two single policies covering the two adults of a childless couple unit, we add these together. Premiums are prorated to account for the number of months of coverage during the year. For employer-sponsored group coverage, employer contributions toward premiums are not included in this analysis.
Person-level insurance status. Results are reported by individual health insurance status which is defined hierarchically for the categories below:
- Private, employer sponsored: people who had at least 1 month of employer-sponsored insurance and no uninsured months in the year.
- Private, nongroup: people who had least 1 month of nongroup private insurance and no uninsured months in the year.
- Public only: people who had public insurance only for all available months in MEPS during the year.
- Part-year uninsured: people whose number of uninsured months is less than the number of available months in MEPS during the year.
- Full-year uninsured: people whose number of uninsured months is equal to the number of available months in MEPS during the year.
Total family income. Total family income is the sum of person-level pretax total income, refund income, and sales income.
Round-specific variables—For analytic data collected during specific rounds, age and other population variables were also defined using the round-specific variables. In some cases, missing values were replaced with the value from the closest prior round.
MEPS estimates were generated for each year 2002-2010. Standard errors of the estimates were provided to permit an assessment of sampling variability. All estimates and standard errors were derived using SUDAAN statistical software, which accounts for the complex survey design of MEPS.
All estimated proportions and ratios are weighted to reflect the experiences of the U.S. civilian noninstitutionalized population at the aggregate and subpopulation levels. Person-level weights, specific to the SAQ and DCS, were used for measures derived with data from these supplements. For other person-level measures, including those from the Child Health and Preventive Care section, the overall person-level weight was used. In analyzing data from the Child Health and Preventive Care section, the full file should be used subset to those cases eligible for this section. More information about these weights is available from the MEPS Web site: http://www.meps.ahrq.gov.
In analyzing data from the DCS, a "diabetes pseudo-weight" was used with the file subset to cases where the original DCS weight is positive in order to produce the same variance estimates using different statistical software. The “diabetes pseudo-weight” was defined to equal the diabetes weight when the diabetes weight is positive, to equal 1 when the diabetes weight is zero and the SAQ weight is positive; and is set as undefined when the SAQ weight is zero.
Some MEPS measures were age adjusted to the 2000 U.S. standard population. Among the measures that are age adjusted are the following pertaining to:
- Adult current smokers.
- Adults with obesity.People with office-based or outpatient department visits.
- People who received prescription medications.
- People with hospital emergency department visits.
- People who had hospital inpatient discharges.
Measures pertaining to children were not age adjusted. Table 1 lists measures that are age adjusted in the 2013 NHQR and NHDR and provides information about the age groups used for adjustment.
Table 1. Age-adjusted measures in the 2013 National Health Care Quality Report and National Health Care Disparities Report
|Measure Title||Age groups used in Adjustment (Years)|
|Composite measure: Adults age 40 and over with diagnosed diabetes who received all four recommended services for diabetes in the calendar year (two or more hemoglobin A1c measurements, dilated eye examination, foot examination, and flu shot)||40-59, 60+|
|Adults age 40 and over with diagnosed diabetes who received two or more hemoglobin A1c measurements in the calendar year||40-59, 60+|
|Adults age 40 and over with diagnosed diabetes who received a dilated eye examination in the calendar year||40-59, 60+|
|Adults age 40 and over with diagnosed diabetes who had their feet checked for sores or irritation in the calendar year||40-59, 60+|
|Adults age 40 and over with diagnosed diabetes who received an influenza vaccination in the last 12 months||40-59, 60+|
|People with current asthma who are now taking preventive medicine daily or almost daily (either oral or inhaler)||0-17, 18-44, 45-64, 65+|
|Adult current smokers with a checkup in the last 12 months who received advice to quit smoking||18-44, 45-64, 65+|
|Adults with obesity who ever received advice from a health provider to exercise more||18-44, 45-64, 65+|
|Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods||18-44, 45-64, 65+|
|Adults with obesity who did not spend half an hour or more in moderate or vigorous physical activity at least three times a week||18-44, 45-64, 65+|
|People who had an office-based or outpatient department visit in the calendar year||0-17, 18-44, 45-64, 65-74, 75+|
|People who received a prescription medication in the calendar year||0-17, 18-44, 45-64, 65-74, 75+|
|People who had a hospital emergency room visit in the calendar year||0-17, 18-44, 45-64, 65-74, 75+|
|People who received a hospital inpatient discharge in the calendar year||0-17, 18-44, 45-64, 65-74, 75+|
Consistent with the established criteria for data reporting in the NHQR and NHDR, MEPS estimates are suppressed when they are based on sample sizes of fewer than 100 or when their relative standard errors are 30% or more. Records in which analytic variables have missing values were excluded for analysis.
1. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012 Apr;60(4):616-31 [35 references]. Abstract on PubMed®.
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