MEPS Annual Methodology Report 2024

Final Report
Westat Reference Number: 2-7-736
Deliverable Number: 121bE.102
Contract Number: 75Q80120D00024
July 1, 2025

Prepared For
Agency for Healthcare Research and Quality
Center for Financing, Access, and Cost Trends
560 Fishers Lane
Rockville, MD 20850

Prepared By
Westat
1600 Research Boulevard
Rockville, MD 20850-3129
301-251-1500

Table of Contents

Introduction
1. Sample
1.1 Sample Composition
1.2 Sample Delivery and Processing
2. Instrument and Materials Design
2.1 Introduction
2.2 Overview of MEPS Instruments
2.3 Instrument Changes for 2024
2.4 Testing of the Instruments and Interviewer Management System
2.5 Changes to Materials and Procedures for 2024
2.5.1 Instructional Manuals
2.5.2 Electronic Case Materials
2.5.3 Respondent Materials
3. Recruiting and Training
3.1 Field Interviewer Recruiting for 2024
3.2 2024 Interviewer Training
3.2.1 Experienced Interviewer Training
3.2.2 Continuing Education for All Interviewers
4. Data Collection
4.1 Data Collection Procedures
4.2 Data Collection Results: Interviewing
4.2.1 Components of Response and Nonresponse
4.2.2 NHIS Completion Status
4.2.3 Sample Domain
4.2.4 Refusals and Refusal Conversion
4.2.5 Tracing and Locating
4.2.6 Interview Length
4.2.7 Mean Contact Attempts Per Case
4.3 Data Collection Results: Authorization Form Signing Rates
4.4 Data Collection Results: Self-Administered Questionnaire (SAQ), Diabetes Care Supplement (DCS), and Collection Rates
4.5 Quality Control
4.6 Security Incidents
5. Home Office Support of Field Activities
5.1 Preparation for Field Activities
5.2 Support During Data Collection
6. Data Processing and Data Delivery
6.1 Processing to Support Data Delivery
6.1.1 Schedules for Data Delivery
6.1.2 Data Quality Control System
6.1.3 Transformation
6.1.4 TeleForm/Data Editing of Scanned Forms
6.1.5 Coding
6.2 Data Delivery
6.2.1 Variable Construction
6.2.2 File Deliveries
Appendix A Comprehensive Tables � Household Survey
Tables
Table 1.1. Initial MEPS sample size (RUs) and number of National Health Interview Survey PSUs, all Panels
Table 1.2. Data collection periods and starting reporting unit (RU)-level sample sizes, spring 2019 through fall 2024
Table 1.3. Percentage of National Health Interview Survey (NHIS) households with partially completed interviews in Panels 4 to 29
Table 1.4. Distribution of Panel 29 sampled reporting units (RUs) by sample domain
Table 3.1. Staffing for spring field period, 2020-2024
Table 3.2. Numbers of new hires who accepted positions, were trained and retained in 2024
Table 3.3. Attrition rate among new and experienced interviewers, 2020-2024
Table 3.4. Annual attrition rate among new and experienced interviewers, 2020-2024
Table 4.1. Data collection schedule and number of weeks per round of data collection, 2024
Table 4.2. MEPS-HC data collection results, Panels 23 through 29
Table 4.3. Response rates by data collection year, 2014-2024
Table 4.4. Completed cases by mode of interviewing for Panels 27 through 29
Table 4.5. Summary of MEPS Round 1 response and nonresponse, 2019-2024 Panels
Table 4.6. Summary of MEPS Round 1 response, 2019-2024 Panels, by National Health Interview Survey (NHIS) completion status
Table 4.7. Summary of MEPS Panel 29, Round 1 response rates, by sample domain by National Health Interview Survey (NHIS) completion status
Table 4.8. Summary of MEPS Panel 29, Round 1 response by interview mode, sample domain, and National Health Interview Survey (NHIS) completion status
Table 4.9. Summary of MEPS Round 1 results for reporting units who ever refused, Panels 23 through 29
Table 4.10. Summary of MEPS Round 1 results for reporting units who were ever traced, Panels 23 through 29
Table 4.11. Interview timing comparison, Panels 23 through 29 (mean minutes per interview, single-session interviews)
Table 4.12. Interview timing comparison by interview mode for Panels 27 through 29 (mean minutes per interview, single-session interviews)
Table 4.13. Mean contact attempts by National Health Interview Survey (NHIS) completion status and interview mode, Round 1 of Panels 27 through 29
Table 4.14. Signing rates for medical provider authorization forms for Panels 22 through 29
Table 4.15. Signing rates for pharmacy authorization forms for Panels 22 through 29
Table 4.16. Results of self-administered questionnaire (SAQ) collection for Panels 22 through 29
Table 4.17. Results of Diabetes Care Supplement (DCS) collection for Panels 21 through 28
Table 5.1. Number and percentage of respondents who called the respondent information line, 2020-2024
Table 5.2. Calls to the respondent information line, 2023 and 2024
Table 6.1. 2024 cases with comments or data check issues
Table 6.2. Total number of comments by category
Table A.1. Data collection periods and starting RU-level sample sizes, all Panels
Table A.2. MEPS household survey data collection results, all Panels
Table A.3. Response rates by data collection year
Table A.4. Summary of MEPS Round 1 response and nonresponse
Table A.5. Summary of Round 1 response by NHIS completion status
Table A.6. Summary of MEPS Round 1 results for all RUs who ever refused, Panels 15-29
Table A.7. Summary of MEPS Round 1 results for RUs who were ever traced, Panels 15-29
Table A.8. Interview timing comparison (mean minutes per interview, single-session interviews)
Table A.9. Mean contact attempts by NHIS completion status, Round 1
Table A.10. Signing rates for medical provider authorization forms
Table A.11. Interview length by mode for Panels 24-29
Table A.12. Signing rates for pharmacy authorization forms
Table A.13. Results of self-administered questionnaire (SAQ) collection
Table A.14. Results of Diabetes Care Supplement (DCS) collection
Table A.15. Results of patient profile collection
Table A.16. Calls to respondent information line
Table A.17. Files delivered during 2024
Figures and Exhibits
Figure 6.1. Blaise to Dex transformation
Exhibit 2.1. Round 1 interview flow
Exhibit 2.2. Supplemental sections by round
Exhibit 2.3. Authorization forms by round
Exhibit 2.4. Supplemental self-administered questionnaires by 2024 field period and round

Introduction

The Household Component of the Medical Expenditure Panel Survey (MEPS-HC; Contract 75Q80120D00024, awarded July 13, 2020 and Contract 75Q80124D00001, awarded September 24, 2024) is the central component of the long-term research effort sponsored by the Agency for Healthcare Research and Quality (AHRQ) to provide timely and accurate data on access to, use of, and payments for healthcare services by the U.S. civilian noninstitutionalized population. The project has been in operation since 1996, each year producing a series of annual estimates of health insurance coverage, healthcare utilization, and healthcare expenditures. This report documents the principal design, training, data collection, and data processing activities of the MEPS-HC for survey year 2024.

Data are collected for the MEPS-HC through a series of overlapping household Panels. The sample is drawn from the previous year’s National Household Interview Survey (NHIS). Each year a new Panel is enrolled for a series of five in-person or video interviews conducted over a 2.5-year period covering two calendar years of data. Supplemental self-administered questionnaires obtain additional information from adults in the household.

This report describes work performed for all the Panels active during calendar year 2024. Data collection operations in 2024 were for Panel 27, Round 5; Panel 28, Rounds 3 and 4; and Panel 29, Rounds 1 and 2. Data processing activity focused on delivery of full-year utilization and expenditure files for calendar year 2022. Tables in the body of the text highlight the 2024 results, with limited comparison to prior years. A set of tables showing data collection results over the history of the project is included in the appendix.

Chapter 1 of the report describes the 2024 sample and activities associated with preparing the sample for fielding. Chapters 2 through 5 discuss activities associated with the data collection for 2024: updates to the survey questionnaire and field procedures; field staff recruiting and training; data collection operations and results; and home office support of field activities. Chapter 6 describes data processing and data delivery activities.

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1. Sample

Each year, a new, nationally representative sample for the Medical Expenditure Panel Survey Household Component (MEPS-HC) is drawn from among households responding to the previous year’s National Health Interview Survey (NHIS). Households in a new Panel typically participate in a series of five interviews that collect data covering two full calendar years. For each calendar year, the sample respondents from two Panels�one completing its first year in the study (Round 3) and one completing its second year (Round 5)�are combined for analysis purposes, resulting in a series of annual estimation files.

The sample for the new MEPS Panel in 2024, Panel 29, was selected from among households responding to the NHIS in the preceding year, where the NHIS sample was based on the NHIS sample design initially implemented in 2016 (as were Panels 22-28). Specifically, the MEPS household sample was randomly selected from among those that participated in the NHIS during the first three quarters of 2023 and who had been assigned to NHIS Panels 1 and 3, the NHIS Panels designated for MEPS.

This chapter describes the 2024 MEPS sample drawn from 2023 NHIS-responding households as well as steps taken to prepare the new sample for fielding.

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1.1 Sample Composition

Table 1.1 shows the starting sample sizes in terms of the number of reporting units (RUs) for all MEPS Panels through Panel 29 and the number of MEPS primary sampling units (PSUs) from which each Panel was drawn. Note that the change in the number of PSUs for Panel 12 reflects the redesign of the NHIS sample implemented in 2006 (thus affecting MEPS in 2007), following the 2000 Decennial Census. The number of PSUs for Panel 29 is based on the number of PSUs associated with MEPS after the 2016 NHIS sample redesign, the eighth such MEPS Panel under this design. The reduction in the number of PSUs after Panel 22 stemmed from further modifications to the NHIS design. The MEPS sample units presented are RUs, each of which represents a set of related persons living together within the same NHIS-responding household selected for MEPS participation. Related members of the NHIS households sampled for MEPS who move as a unit during the MEPS data collection period (as well as separate individuals) form new RUs for interviewing purposes. Each new RU is followed over the course of the five MEPS data collection Rounds and interviewed at their new address.

* RUs: reporting units; PSUs: primary sampling units

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MEPS data collection is conducted in two main fielding periods each year. Typically, during the January-June period, Round 1 of the new Panel and Rounds 3 and 5 of the two continuing Panels are fielded, with the Panel in Round 5 retiring at midyear. Normally, during the July-December period, Round 2 of the new Panel and Round 4 of the remaining continuing Panel are fielded.

Table 1.2 summarizes the combined workload for the January-June and July-December periods from spring 2019 through fall 2024.

Over the years shown in Table 1.2, the combined spring and fall workload has ranged from a low of 28,566 in 2023 to a high of 40,168 in 2021. Typically, the interviewing workload during the spring field period, when three Panels are active, is substantially larger than during the fall, when there are only two. In 2024, there were three active Panels in the spring field period and two in the fall field periods. The spring field period had more cases, with an increase in Round 1 sample to 10,424. A total of 20,678 cases were fielded in spring, while the fall workload had 11,654 RUs.

* RU-level sample size for this table was derived from field management system counts and operational reports detailing the fielded sample.

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Each new MEPS Panel includes some oversampling of population groups of particular analytic interest. Since 2010 (Panel 15), the set of sample domains has included oversamples of Asian, Black, and Hispanic populations. All households set aside in the NHIS for MEPS that have at least one household member in any of these three categories (Asian, Black, or Hispanic) are included in the MEPS sample with certainty. “White and other race” households have been partitioned into two sample domains and subsampled at varying rates across the years. These domains reflect whether an NHIS-responding household characterized as “White or other race” provided “complete” information at the household level for the NHIS or if only “partially complete” information was provided.

As background, the partitioning of the “White, other” domain into these two domains began in 2011 (Panel 16). The partial completes were sampled at a lower rate than the full completes in order to lessen the impact on the field effort resulting from the difficulty of gaining the cooperation of these households. The last two columns in Table 1.3 show the subsampling rates for the two groups since Panel 16. Prior to Panel 29, the partial completes in the “White, other” domain have been subsampled at rates ranging from a low of 40 percent (Panel 17) to a high of 80 percent (Panel 27). For Panel 29, to maximize the sample size amid concerns about response rates, all partial completes in the “White, other” domain were kept in the sample. Table 1.4 shows the Panel 29 sample distribution by domain. It should be noted that partial completes historically require more effort, are more likely to refuse, and result in a significantly lower response rate.

* The figures in the second column of the table are the proportion of partial completes in the total delivered sample, after subsampling. The figures in the third and fourth columns are subsampling rates applied to the two “White, other” subdomains in Panels 16 through 29.

**Note that Panel 26 rates were left blank due to subsampling being done by size of state rather than race/ethnicity domain.

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1.2 Sample Delivery and Processing

The 2024 MEPS sample was received from AHRQ and the National Center for Health Statistics (NCHS) in two deliveries. The first delivery, containing households sampled from the first and second quarter of the 2023 NHIS, was received on September 13, 2023. Households selected from the third quarter of the NHIS were delivered on November 28, 2023.

The September delivery of the first majority of the new sample is instrumental to the project’s schedule for launching interviewing each year in early January. The partial file gives insight into the demographic and geographic distribution of the households in the new Panel. This information, when combined with information on older Panels continuing in the new year, guides project decisions on the number and location of new interviewers to recruit.

Upon receipt of the first portion of the 2024 sample, project staff also reviewed the NHIS sample file formats to identify any new variables or values and to make any necessary changes to the project programs that use the sample file information. Following this initial review, staff proceeded with the standard processing through which the NHIS households are reconfigured to conform to MEPS reporting unit definitions and prepared the files needed for advance mailouts and interviewer assignments. The early sample delivery also allows time for checking and updating NHIS addresses to improve the quality of the initial mailouts and to identify households that have moved since the NHIS interview.

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2. Instrument and Materials Design

2.1 Introduction

This chapter describes the overall design of the instruments and materials used to collect MEPS-HC data. The notable changes made for 2024 are detailed, as well as the procedures for testing these changes prior to implementation.

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2.2 Overview of MEPS Instruments

MEPS-HC interview data are collected through a Computer-Assisted Personal Interview (CAPI) instrument. Since 2018, the MEPS-HC CAPI instrument has been programmed in Blaise 4.8. Both an English and Spanish version of the instrument are available. The same CAPI instrument is also used for Computer-Assisted Video Interviewing (CAVI).

The MEPS-HC CAPI instrument is divided into sections that deal with specific topics such as medical conditions, visits with health care providers, hospital stays, health insurance, and prescribed medicines. Certain core questions are asked in every round of the study, while other questions are asked in specific rounds only. Information collected for a household in previous rounds is brought forward into the current round’s interview to be updated so that a complete picture of a household’s medical care and the cost for that care will be captured for a two-year period over the course of five rounds of interviewing. The CAPI instrument’s ability to tailor each interview to reflect the experiences of each household reduces the burden on interviewers and respondents and allows MEPS-HC interviews to proceed more smoothly.

The basic flow of the Round 1 MEPS-HC interview is displayed in Exhibit 2.1.

Exhibit 2.1. Round 1 interview flow

During Rounds 2-5, “supplemental” sections are added to the core MEPS-HC interview content. Exhibit 2.2 lists the current supplemental sections as of 2024 and which rounds they are administered in. Periodically these supplemental sections will be updated or replaced.

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In the Respondent Forms section of the CAPI instrument, authorization forms are collected and/or distributed. MEPS collects signed medical provider authorization forms for key household members who have received medical care from certain types of providers. MEPS also collects signed pharmacy authorization forms for key household members who obtained prescriptions drugs from a pharmacy or by mail order. These signed authorization forms allow MEPS to contact health care providers directly for information to supplement the data collected during the household interview. Getting authorization to contact these providers is essential to the success of MEPS.

Exhibit 2.3 lists the MEPS authorization forms and which rounds they are requested in. During Round 1 interviews, medical provider authorization forms are only requested for hospital-based care, including hospital stays (HS), emergency room (ER), and outpatient department (OP) events. During Round 2-5 interviews, authorization forms are also requested for medical provider visits (MV), home health (HH), institutional care (IC), and telehealth (TH) events, as well as for pharmacies.

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To complement the main MEPS-HC interview, key adult household members are also asked to complete one or more supplemental self-administered questionnaires (SAQs). The topics of these SAQs rotate. Four unique SAQs were requested or followed-up on during 2024, as shown in Exhibit 2.4.

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In the Quality Supplement section of the CAPI instrument, SAQs are discussed and requested. Most MEPS SAQs are available as multimode web or paper questionnaires, though the Diabetes Care Supplement (DCS) is only available as a paper questionnaire. All MEPS web SAQs are hosted at www.MEPSDocs.org/survey. Every invitation and reminder message about web SAQs includes this URL, as well as a unique personal identification number (PIN) the household member must use to log in to their survey.

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2.3 Instrument Changes for 2024

For each data collection cycle, AHRQ and Westat work together to define a set of modifications to the CAPI instrument and SAQs. Some modifications are new items or new sections, whereas others are updates or fixes to existing items. The notable changes for 2024 are summarized below.

Priority Condition Enumeration (PE). Three changes were made in the Priority Condition Enumeration section. The first change was updating the COVID-19 and Long COVID series to only be asked in spring rounds for most RU members. In fall rounds, these items will only be asked for new RU members. In addition, initial items about COVID-19 and long COVID (PE350, PE362) will only be asked if these conditions were not reported in prior rounds. The second change was that PE370 (which asks if the RU member has had COVID-19 within the past 12 months) was revised to a yes/no question with new fill of “a new infection” for those who reported prior COVID-19. The third change was the addition of a soft check to PE380 (which records the month and year a RU member last had COVID-19) to discourage dates from more than 12 months ago from being reported.

Condition Lookup. The condition lookup is a trigram search tool embedded within the CAPI instrument that accurately captures approximately 1100 of the most common conditions coded to an ICD-10 code on MEPS. The lookup allows interviewers to easily find the correct condition without leading them to an inaccurate entry. In 2024, the condition lookup was updated with 12 additional entries. The proposed additions were developed based on a review of conditions entered via manual entry for DY2022 data. As with previous cycles, a cutoff of 5 manual entries was used to identify potential items for adding to the pick list. After all potential items were identified, they were reviewed to assess suitability for the pick list. During this review process, some potential items were removed if they were found to be redundant with existing pick list entries or did not contain sufficient detail.

Prescribed Medicine Lookup. Similar to the Condition lookup, the Prescribed Medicine lookup is a search tool within CAPI that accurately captures approximately 2300 of the most common prescribed medicines on MEPS. In 2024, the prescribed medicine lookup was updated with 60 additional entries. Westat’s approach to identifying potential additions started with reviewing all the manual entries reported in DY2022. New entries were identified if they were manually reported 20 or more times and one of the three following three categories:

• Prescribed medicines not currently in the pick list.
  
  
• Prescribed medicines with a related entry currently in the pick list, yet reported 20 or more times with a substantively different strength or form.
  
  
• Unspecified entries without a specific medicine name.

Provider Probes (PP). Two changes were made in Provider Probes. The first was a result of listening to computer-assisted recorded interviewing (CARI) recordings (more on CARI in Section 4.1). At item PP40, which asks about care received for a primary care doctor, interviewers were skipping the word “pediatrician” when interviewing RUs without any children. To accommodate verbatim reading, brackets were added around the word “pediatrician,” allowing the interviewers to opt out of reading the word when it is not applicable.

A change was also made to PP70, which asks about care received at clinics, to be more inclusive about the examples mentioned. AHRQ requested wording changes to specifically refer to “shots and vaccines,” as well as care received from a “pharmacy” to encourage reporting of vaccines received during the reference period.

Charge/Payment (CP). Several changes were made to the CP section to ease interviewer and respondent burden. The first change was made at CP150 which collects the total charge. The answer field was expanded to accept 7 digits rather than 6 to accommodate higher dollar values. However, to help prevent keying errors, soft checks were also added to this item. The soft check minimum and maximum range vary by event type and will be updated as needed each year. An update was also made to corresponding flat fee item FF140 to reflect this change.

A new item was also added that verifies the total charge of events that are part of repeat visit groups, when they are reported to be > $5,000. AHRQ noticed that some respondents may be erroneously combining total charges for multiple repeat visit events, resulting in inaccurate data. The new item confirms that the total charge reported corresponds to the single event requested; if not, instructions are provided for backing up to correct the issue.

Financial Well-Being (FW). As requested by AHRQ, a new CAPI section with five questions was added for all RUs in fall rounds to capture information regarding the household’s financial health. Items include questions on whether the household was late or unable to pay rent/mortgage, credit card or utility bill, and whether they were ever contact by a debt collection agency or could come up with $400 for unexpected expenses. These items originally appeared in the 2021 Social Determinants of Health (SDOH) SAQ and the 2022 Preventive Care SAQ (PSAQ).

Food Security (FS). The universe for this section was expanded to all RUs, including proxies and student RUs. Revising the FS section universe aligns with the universe for the FW section (which will now come immediately prior) and also eliminates the need for a separate weight for analyzing the data in this section.

Health Insurance (HX) and Related Sections. A key aspect of health insurance coverage is the period of time someone is covered, referred to as their “coverage period.” In CAPI, each RU member’s coverage period is collected at the HQ10 grid. For spring 2024, MEPS made changes to the HQ10 grid to facilitate easier reporting when individuals were covered by the same insurance source and had the same reference period dates as the first person on the grid. A new question (HQ10_16) was added at the end of the first row, inquiring who else was covered for the same period as the first person. For RU members selected at HQ10_16, their rows were auto-coded with the same answers as Person 1. This change aimed to reduce the time and burden of administering the grid, especially in larger RUs with multiple people covered by the same insurance. In fall 2024, two new questions were added to the end of the Health Insurance section to gather information regarding household medical debt, expanding the scope of data collection to address the financial impact of healthcare.

Contacting Module (CM). Updates were made to questions about permission to text RU members. Previously, we asked if each adult cell phone owner was available to talk immediately, and if so, asked them directly for permission to send text messages to their cell phone. For spring 2024, this was simplified such that the household respondent is asked for permission to send text messages on behalf of all adult RU members with cell phone numbers provided. Further wording changes were implemented in the fall 2024. To ensure transparency and provide respondents with crucial information when asking for permission to text, the phrase “Please note that message and data rates may apply” was added.

Quality Supplement (QS) and SAQs. Traditionally, MEPS SAQ requests have been introduced during the main household interview, in the QS section. For fall 2024, the multimode SAQ protocol was revised such that individual web SAQ invitations to eligible household members were included as part of the advance package sent to each household at the beginning of the field period. As a result, many people started or completed SAQs before their household’s interview. Multiple MEPS systems were revised to allow for the latest SAQ statuses to be synced to each interviewer’s laptop approximately every 15 minutes. These SAQ statuses are then preloaded in the CAPI instrument when the interview is launched. The QS section was updated so that it displays the latest status of each requested SAQ, and customized the text and routing based on the status. For example, if a household has completed all of their requested SAQs, the interviewer thanks them and moves on to the next section; if the household has not yet started any of their requested SAQs, the interviewer provides further information about which people are eligible for SAQs and how to complete them.

As previously summarized in Exhibit 2-4, there were four MEPS SAQs administered in 2024. The content of the “Your Health and Health Opinions” SAQ (follow-up from Spring 2023) and Diabetes Care Supplement were both unchanged from prior years.

The preventive care PSAQ previously had separate versions of the paper questionnaire for males and females, but for 2024 these were combined into a single paper version for both sexes to allow for more similarity between the paper and web modes. This required some revisions to question order, skip logic, and layout of the paper form. Furthermore, a few questions related to financial well-being were removed from the PSAQ as they were added to the main household interview.

The cancer SAQ (CSAQ) was revived for 2024; the last time MEPS fielded the CSAQ was in 2017. About two-thirds of the CSAQ content was the same or very similar to the prior administration, but many items were new. The new content included questions about impacts of cancer on employment, long-term side effects of cancer or its treatment, and cancer-related follow-up care.

Closing (CL). Towards the very end of the interview, a new screen was added where the interviewer reminds the respondent of all the household’s outstanding follow-up tasks, including AFs and SAQs. The interviewer also fills out a complementary follow-up card (similar to a postcard) which lists each RU member and their outstanding tasks.

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2.4 Testing of the Instruments and Interviewer Management System

Testing for the spring 2024 (Rounds 1, 3, and 5) instruments was conducted between September and December 2023. Testing for the fall 2024 (Rounds 2 and 4) instruments was conducted between March and June 2024. Since 2018, many of the testing approaches and procedures used for the technical upgrade have been continued or adapted to maintain a comprehensive testing plan that supports the ongoing instrument development schedule.

CAPI instrument development and testing included multiple programming/testing iterations that each lasted several weeks. Testing was conducted by a mix of corporate testers, MEPS project staff, and trained programming staff. Project and systems staff performed all testing in close coordination with the design team. For each of the spring and fall instruments, AHRQ received an alpha delivery and conducted its own testing. The following month, AHRQ received a beta delivery and conducted additional testing.

The testing ensured that CAPI followed the design as intended and assessed whether the layout of the overall screen for a given question, and across questions, consistently met the requirements designed to minimize measurement error. Feature testing thoroughly tested all new features against specifications including wording, text fills, legal and illegal responses, boundary conditions, and skip patterns. Testers validated every possible variation allowed by the specifications.

Both scripted and free-form testing were used throughout the development and testing process. A full suite of scripted test cases was defined by the design staff and analytic leads at Westat and is updated each cycle. These scripted test cases represent approximately 80 percent of the cases fielded, including common paths through the CAPI instrument across all Panel Rounds. The test script suite was executed through alpha and beta for the spring and fall testing cycles.

In contrast, free-form testing focused on design changes in the current instrument build and ensured that any reported instrument bugs had been fixed. Free-form testing was also utilized to ensure the stability of the CAPI data model and to evaluate the stored data in new or unusual situations. Testers routinely pushed array limits, used back-up, changed answers, and used break-off and restart cases to challenge performance boundaries.

Additional testing components, including enhanced integration testing and ad hoc/free-form testing, were also conducted. The enhanced integration testing allowed project staff to check electronic face sheet information, test the RU Information module and the Interviewer Assignment Sheet (IAS), and make entries into the electronic record of calls and refusal evaluation form. The ad hoc testing component used information derived from actual cases to verify that all management information was brought forward correctly from previous rounds. Using actual case data also allowed staff to check uncommon paths through the MEPS instrument so that specific changes to the questionnaire could be thoroughly tested.

The fall 2024 development cycle also included extensive testing related to multimode SAQs. This included unit and integrated testing of the revised screens and routing in the CAPI instrument and the web version of the SAQ, data entered via web, text and email invitations and reminders, the MEPSDocs website, and receipt procedures, including the use of various devices to access and complete the web surveys.

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2.5 Changes to Materials and Procedures for 2024

The manuals and the materials for the 2024 field effort were updated as needed to reflect changes to the questionnaire and management systems. Below is a description of the key changes to the materials and procedures.

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2.5.1 Instructional Manuals

The field interviewer procedures manual was updated to address changes in field procedures and updates to the Interviewer Management System (IMS). For 2024 this included revising the IMS and SMS (Study Management System) appendices for the new Advanced Field Operating System (AFOS) and updating all images of the IMS and SMS throughout the manual.

In addition, starting in 2024 the manual was available electronically on the MEPS laptop only. Hard copies are no longer distributed.

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2.5.2 Electronic Case Materials

To help prepare for upcoming interviews, the electronic face sheet in the IMS provides interviewers with information needed to contact their assigned households and familiarize themselves with the composition of the household and relevant details about their prior history with the survey. No changes to the data on the face sheet were made in 2024, however the face sheet user interface was updated as part of the AFOS migration, providing a more modern look and improved navigation.

To document activities while working their cases, interviewers enter Electronic Record of Calls (EROCs) and have the ability to update contacting information and enter field notes in their IMS.

At the conclusion of the household interview, the respondent is given a $50 prepaid debit card to thank them for their participation. To activate the debit card, the interviewer completes a Payment module in the IMS by typing a unique activation code into the module twice.

An RU Information module is also completed after every interview by the interviewer to document operational information to help the next Round’s interviewer effectively work each case.

To support follow-up for authorization forms and SAQs not completed at the time of the interview, an online module in the SMS provides the information interviewers need to follow-up and the ability to document their follow-up efforts.

Interviewers continued to be equipped with iPhones and the mobile field operating system (MFOS) application for their MEPS work. Many of the same features available in the IMS were available in MFOS, including viewing face sheets, entering EROCs, updating contact information, taking notes, and completing the RU information module. However, the Payment module and online follow-up module are not available in MFOS.

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2.5.3 Respondent Materials

Annual updates were made to all respondent letters, the monthly planner, self-administered questionnaires, and the Income Job Aid. For 2024, no significant changes were made to the design or content of other respondent materials.

The MEPSDocs.org website continued to be available to respondents to boost cooperation, ease legitimacy concerns, and offer record-keeping tools. In addition, the MEPSDocs website also has links to the show cards in both English and Spanish that are accessed by interviewers during CAVI interviews (using Zoom to display the show cards), as well as by respondents during telephone interviews. The MEPSDocs website also hosted the web SAQ during the fall 2024 field period.

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3. Recruiting and Training

3.1 Field Interviewer Recruiting for 2024

Overview. MEPS started spring 2024 data collection with 259 experienced interviewers. Throughout 2024, there were three recruiting periods to increase staffing to about 325 interviewers.

We calculated staffing needs based on projected completes and hours per complete, based on staff committing to a part time schedule of 20 hours per week. In addition, MEPS collected data in 132 different primary sampling units, which can encompass multiple counties, including across state borders, so location adds to the complexity of estimating the staff needed. The goal is not only to have enough personnel to meet targets but also to reduce the need for travel.

All MEPS staff are trained to conduct Computer Assisted Video Interviews (CAVI). In Spring of 2024, MEPS deployed a team of 17 interviewers focused primarily on completing CAVI cases throughout the country � this group completed almost 1,400 interviews. Using this team and other staff, including the 6 members of the MEPS travel team, to support unstaffed PSUs This team helped MEPS attain its production goals and reduce costs in these unstaffed areas by providing coverage respondents willing and able to participate via CAVI.

To put the recruiting and attrition numbers into historic perspective, Table 3.1 summarizes the MEPS staffing for the period of 2020-2024.

* Note that the new interviewers staffed includes the interviewers who were trained throughout the year’s attrition trainings. This column represents the total number of new interviewers staffed for the entire year shown.

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Recruiting. Westat uses the Field Interviewer Recruitment Module (FIRM) software designed to manage the data collector recruiting process. This system works in conjunction with BrassRing, an online application system used to collect, track, and manage applications for all positions at Westat. The BrassRing system collects applications from both external (new to Westat) and internal (current or former Westat field data collectors) applicants.

MEPS conducted three trainings in 2024 in January, April and August. Table 3.2 shows the number of candidates who accepted field interviewer positions, the number of new hires who completed training and the number who remained on MEPS at the end of fall data collection in December 2024.

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Recruiting began three months in advance of each training with the goal of hiring local staff in unstaffed or understaffed PSUs or traveling staff to cover those areas.

Interviewer Attrition During 2024 Data Collection. During the spring data collection, 17 new interviewers and 43 experienced interviewers were lost to attrition. An additional 22 new interviewers and 21 experienced interviewers were lost during the fall round. The breakdown of 2024 interviewer attrition is shown in Tables 3.3.

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*New interviewer attrition includes attrition from the two spring trainings (January and April), as well as the supplementary August training to bolster the fall data collection staff. 12 interviewers were lost from the spring training (29.2%) and 10 from the fall training (32.3%)

Table 3.3 shows the overall attrition rate during the spring and fall data collection periods from 2020 through 2024. The total spring 2024 attrition rate of 18.9 percent, which is the same as the 2023 attrition rate. However, it remains lower than any year since 2020 is lower than in 2020-2022.

Table 3.3 also shows the overall attrition rate during the fall data collection period from 2020 through 2024. The total fall 2024 attrition rate was 14.9 percent, slightly higher than the prior two years’ attrition rates and reflecting a higher new hire attrition rate in 2024 due to attrition from the August new hire training that was new in 2024.

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Total attrition for the year (as shown in Table 3.4) was 30 percent, similar to prior years. The average annual attrition rate among new hires has been 48.8 percent and 22.9 percent among experienced interviewers. In looking forward to 2025, MEPS will again aim to expand the interviewing staff to approximately 325 interviewers.

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3.2 2024 Interviewer Training

The overall structure for training new interviewers in 2024 was drawn from the 2023 training plan. The goals of the 2024 trainings were to address the challenges associated with the recruitment and retention of field data collectors through several approaches including engagement of new hires between the time of hire and in-person training, the reduction of the length and complexity of training, and additional opportunities for interaction between new hires and existing field data collectors.

The 2024 training package reflected a blended training approach that included 5.5 days of in-person training that focused on later round interviewing, preceded by asynchronous and synchronous virtual content; CAVI training as part of in-person training, with post-training follow-up; a post asynchronous training on additional topics; and a 2-day virtual training that focused on Round 1 interviewing.

To enhance recruitment and training efficiency, Westat successfully conducted its first new hire training during a fall interviewing cycle, moving away from the challenging January schedule. This initiative aligned with our longstanding goal of separating later round training from Round 1 training. By introducing new hire training in August, Westat pilot tested a training session covering all later rounds, rather than only Rounds 3 and 5. This approach provided new hires with nearly five months of experience in later round interviewing before they were introduced to Round 1. This model has several key strengths. It enhances interviewer confidence by allowing them to gain substantial experience and confidence through focusing on later rounds first. Additionally, starting Round 1 in 2025 with a workforce that has already honed their skills in later rounds ensures higher quality and efficiency. Conducting training in the fall avoids the recruitment challenges typically faced in January.

Welcome to MEPS Pre-training Activities. This package included a project laptop, phone equipment, and an interactive self-paced workbook with exercises and online modules, including videos and knowledge checks, administered through Westat’s Learning Management System (LMS). The LMS generated regular reports, allowing home office and field management staff to monitor the completion of each trainee’s home study. New hires received their home study package early enough to complete the assignments before the in-person training, but not so early that their introduction to important study concepts and project terminology would degrade before the in-person training. The training added additional practice with the Zoom platform prior to the in-person training. New hires also participated in a pre-classroom virtual Welcome to MEPS session. The goals of the session were to further familiarize the new hires with the Zoom platform in preparation for CAVI interviewing and future virtual sessions for Round 1 content, and to contextualize the MEPS training experience using both training staff and experienced field staff.

In-Person Training. For the 5.5 days of project-specific training, each trainee was assigned to one of four training classrooms for the January training or two classrooms for the April and August attrition trainings. Classrooms were staffed by a primary trainer and a support trainer and one or two classroom runners. The selection of trainers for the 2024 new hire training was based on several criteria, including experience training with the CAPI instrument, overall project knowledge, and prior training experience. Prior to in-person training, all training and support staff received a training on the content, activities, and procedures, roles, responsibilities, and coordination associated with training.

The training sessions used a variety of formats for presenting material, including lecture, question-and-answer interactions, written exercises, group discussion of problems and resolutions, and activities in which trainees were required to seek answers by consulting project resource materials. Westat added an additional mock interview to the agenda for a total of two full mock interviews and “mini” mock interviews and dyad role plays were used throughout the training, and they were central to training on both the mechanics and substance of the CAPI instrument.

Mocks are scripted interviews usually led by a classroom trainer who serves as both trainer and “respondent” while trainees take turns as the interviewer. Full mocks present the entire interview from Reenumeration through Closing, while a “mini” mock relies on preloaded data to allow the training to begin at the desired questionnaire section.

Dyads paired trainees to conduct an interview with one in the role of interviewer and the other using a script to play the respondent. During dyad sessions, members of the classroom training team circulate to answer questions and/or work with individuals or pairs of trainees as needed. Dyads are an effective tool for reinforcing questionnaire concepts and building interviewer confidence in administering the instrument. They also provide trainers with an opportunity to assess each trainee’s interviewing skills and mastery of the questionnaire application.

To prepare new hires for CAVI interviewing, CAVI was integrated into the training program. Trainees had the opportunity to practice technical setup and cooperation techniques at in-person training.

The in-person training component maintained the emphasis on interviewer behaviors and interviewing techniques that facilitate complete and accurate reporting. Trainers were instructed to reinforce good interviewing behaviors during mock interviews. Good interviewing behaviors include reading questions verbatim, training respondents to use records to aid recall, actively engaging respondents in the use of show cards, and using active listening and probing skills. Trainers called attention to instances in which interviewers demonstrated such behaviors. To enhance trainee awareness of behaviors that affect data quality, dyad scripts included instructions to take a “time-out” at certain items in the interview to highlight relevant data quality issues.

Trainees who required remedial practice worked one-on-one with training staff after the training day. Training staff provided focused practice based on the needs of the trainee.

Twenty-five new hires successfully completed the January training, 26 successfully completed the April attrition training and 21 completed the August training.

Bilingual trainees in the January and August trainings received an additional half-day of bilingual training immediately following the completion of regular project training. Trainees completed a Round 3 dyad in Spanish. Additionally, trainees practiced advanced cooperation in Spanish. Five new interviewers successfully completed the January in-person bilingual training and seven new interviewers complete the August 2024 in-person bilingual training. Bilingual training for new hires during the April training was performed virtually. Five new interviewers completed the bilingual training virtually.

Post-training Activities. After the successful completion of in-person training, new interviewers were required to successfully complete a post-classroom home study before beginning fieldwork. It contained interactive exercises in Basic Field Operation System (BFOS) Secure Messaging (BSM) and CAPI. The home study also included a memo from the field director reviewing their tasks in preparation to interview and provided an “early work period” documentation form to assist them in setting up a work plan with their supervisor and completing tasks in a timely manner.

In addition to the home study, field supervisors engaged in additional post-training activities with new hires. New hires sat in on the report call of an experienced field interviewer and also reviewed assigned cases to report the best contact strategy for each to their supervisor. Field managers and field supervisors coordinated and implemented a mentoring/buddy plan that paired new hires with experienced field interviewers.

The post-training activities also introduced “on-demand” training modules on special topics. These modules were assigned to all new hires as optional on the Westat LMS. The two topics, NHIS Students and MEPS Students, typically are relevant for a small number of field interviewers. While any new field interviewer could review the material, the goal was to provide targeted training for staff who would encounter these particular situations.

After the successful completion of in-person training, new interviewers participated in CAVI practice sessions with Westat staff. This follows the model of the 2023 CAVI interviewing training program.

2-Day Round 1 Virtual Training. Westat presented 2-day trainings on Round 1 concepts in late February 2024 for January new hires, mid-May for April new hires and mid-December for August new hires. Trainees participated in one of two virtual classrooms in February and May (1 virtual classroom in the December training.) All of the training sessions contained a synchronous virtual session and asynchronous sessions delivered by the LMS.

Day 1 of the trainings focused on the CAPI interview in Round 1, including how to train the MEPS respondent, important concepts in the Reenumeration section, and the differences from later round interviewing and data quality in the Round 1 CAPI interview. The Day 1 asynchronous assignments contained mini-mock interviews that focused on the Reenumeration, Calendar, Employment, and Health Insurance sections.

Day 2 focused on the operational tasks associated with the Round 1 interview, including gaining cooperation in Round 1, practicing approaches at the door, and the tasks associated with locating Round 1 households. The asynchronous content on Day 2 of the trainings focused on advanced cooperation skills, exercises on the electronic record of calls, and data quality in Round 1.

Twenty-five new hires completed the February Round 1 training, 26 completed the May training and 21 completed the December training.

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3.2.1 Experienced Interviewer Training

Spring 2024 Round 1/3/5 Home Study. The Round 1/3/5 home study in December 2023 followed established formats. The 3-hour self-paced program contained an instructional memo and knowledge check, with content on a new laptop and the Windows 11 operating system. The home study introduced the implementation of the Advanced Field Operation System and changes to the Interview Management System. Topics also included the change in the order of the spring rounds, SAQ follow-up procedures, changes to the MEPSdocs.org website, updates to the CAPI instrument and a Health Insurance mini-mock interview.

Fall 2024 Round 2/4 Home Study. The Round 2/4 home study in July 2024 followed established formats. The 2-hour self-paced program contained an instructional memo, interactive self-paced modules on the LMS about multimode SAQ procedures, example materials, and a quiz. Topics included CAVI best practice reminders, updates to the MEPSDocs.org website, multimode SAQ collection, and CAPI updates. New interviewers hired in the spring (January and April) were required to complete a mock interview with their supervisor, field manager, or designated senior interviewer before beginning the fall Rounds of data collection.

Refresher Training. In 2024, AHRQ decided to forgo in-person refresher training. Westat and AHRQ agreed on a new framework for interviewer continuous learning and quality improvement through distance learning. The framework draws on three levels of training components: universal, tailored, and targeted.

In 2024, Westat conducted CARI Rapid Feedback, which personalizes training for veteran field interviewers. Using the CARI system, a group of trained quality control (QC) staff listen to random interviews throughout the field period. These staff code each interview for protocol issues such as: reading verbatim, probing without leading, using show cards and professional rapport. All interviewers receive both positive and negative feedback via email on every case coded. As needed, QC staff coached interviewers in retraining sessions on how they could improve their performance and the importance of following protocols in maintaining high-quality data collection. In weekly contacts with their interviewers, Field Supervisors provided additional individualized instruction and one-on-one coaching.

All field interviewers received links to on-demand videos on topics related to advanced cooperation for MEPS households. The 12 video shorts, organized by respondent concern, demonstrate how a well-trained data collector responds to challenging interview situations. The data collector reviews case materials, develops a game plan, and speaks with the respondent. They use active listening and project knowledge to address the respondent’s concerns.

Training on providing actionable comments was provided to a targeted group of interviewers in 2024. The data quality control (DQC, more in section 6.1.2) home office staff identified interviewers responsible for a high percentage of non-actionable comments and provided customized feedback for this group of interviewers that included specific examples of comments they wrote (removing PII) and how the comment could be improved or why it was unnecessary. Retraining using this material was provided individually to each interviewer by the field directors. FIs were sent, via FedEx, overall and customized training tips along with their actionable/nonactionable comments (removing PII), and a cover email explaining why they received the package. The field director joined the interviewer’s weekly report call with their supervisor and reviewed the material in the Interviewer Quick Reference Guide about critical items for comments.

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3.2.2 Continuing Education for All Interviewers

Weekly Newsletter. In 2024, MEPS continued offering its field interviewer newsletter in a weekly format. The newsletter allows for additional training opportunities in a concise format and the ability to deliver content as needed to the field. Topics included CAPI questionnaire information, procedural content, and answers to field interviewer questions.

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4. Data Collection

This chapter describes the MEPS-HC data collection operations and provides selected results for the six Rounds of MEPS-HC interviewing conducted in 2024. Selected comparisons to results of prior years are also presented. Tables showing results for all years of the study are provided in the appendix.

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4.1 Data Collection Procedures

MEPS data collection management relies on a set of interrelated systems and procedures designed to accomplish three goals: efficiency, data quality, and cost containment. The primary MEPS management system is AFOS, which facilitates case management through case assignment, case status and hours reporting, data quality reporting, and interviewer efficiency. Related systems include the computer-assisted recorded interviewing (CARI) system and the Efficiency Analysis through Geospatial Location Evaluation (EAGLE) Global Positioning System (GPS) validation module. The CARI system allows for review of audio recordings for selected interview items to assist in the assessment of interviewer performance and question assessment. The EAGLE system evaluates the location of an interviewer relative to a respondent’s home which allows for verifying the interview took place. These tools, along with the implementation of models designed to identify cases with a higher propensity for completion, form a comprehensive framework for the management of MEPS data collection.

As in prior years, respondent contact materials provided respondents with the link to the MEPS website (www.meps.ahrq.gov); a toll-free number to Alex Scott, a study representative at Westat; and the link to the Westat website (www.westat.com). Calls received from the Alex Scott line were logged into the call-tracking system, and the appropriate supervisor was notified so that they could take the proper course of action.

The advance contact calls to Panel 29, Round 1 households were made by a subset of the experienced MEPS interviewers.

Typically, for Round 1 households, interviewers are instructed, with a few exceptions, to make initial contact with the household in person. For later Rounds, interviewers are allowed to make initial contacts to set appointments by telephone, so long as the household had been cooperative in prior Rounds.

In 2024, MEPS interviews were conducted in three modes: in-person, CAVI, and telephone (limited). Interviewers were given guidance throughout each field period about which modes were appropriate for their cases, and interview modes were closely monitored. CAVI interviews are conducted via Zoom meetings hosted by the interviewer. Both interviewer and respondent are visible and audible to one another and can share images of records, and interviewers can share show card images to allow respondents to select a response. CAVI interviewing started in late spring 2022 but became pervasive, now accounting for over 26 percent of completed interviews in the Spring Round. Later Round cases were specifically targeted for CAVI interviews; however, these were permissible for Round 1 cases after initial contact. Interviewers typically offered CAVI when respondents were unwilling to have an interviewer in their home or meet them at an appropriate alternative location. For the final round of data collection, Round 5 � 64 percent of cases were completed via CAVI, while Round 3 � 17.5 percent of cases were completed using this mode and by design only 8.6 percent of Round 1 cases were completed via Zoom.

In 2024, authorization forms (AFs) were collected in one of three ways: eSignature, DocuSign, or paper (more detail in Section 4.3) The AF procedures varied based on the interview mode and household contact information provided to MEPS. During in-person interviews, available household members signed on the interviewer’s laptop (eSignature). For household members not available during the in-person interview, or for CAVI or telephone interviews, respondents were sent a link via email or text to sign forms in DocuSign. Paper AFs were still used when requested or for household members unavailable and not eligible for DocuSign due to not providing an email address or cellphone number.

The interview follow-up procedures also varied by mode. For CAVI and telephone interviews, any paper AFs and SAQs were mailed by the interviewer shortly after the interview was completed along with the MEPS incentive � a $50 pre-paid debit card. Pickup of the forms was arranged, or a business reply envelope (BRE) was enclosed for returning the forms directly to the home office. Anytime there were forms requested and not collected during the interview, the interviewer made up to three follow-up calls to ensure DocuSign AFs were signed and/or paper forms were completed and returned.

MEPS field managers and directors continued to manage the field data collection in collaboration with the field supervisors, reinforcing the importance of balancing data quality with production and cost goals across regions.

Throughout the year, Westat continued to review data for all respondents reported to have been institutionalized in order to identify any individuals who might have been inappropriately classified and, as a result, treated as out of scope for MEPS data collection.

Data Collection Schedule. The sequence for beginning the spring Rounds of data collection, most recently adjusted in 2014, was changed for the spring Round of 2024. Data collection began with Round 1, followed by Round 5, and then Round 3. For the Round 1 respondents, the early starting date allowed several additional weeks of data collection.

The field period dates for the Rounds conducted in 2024 are shown in Table 4.1.

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Data Quality (DQ) Monitoring. The MEPS DQ field monitoring system and procedures allowed supervisors and field managers to identify interviewers whose work deviated from quality standards and who might need additional coaching on methods for getting respondents to report their healthcare events more completely. CARI review was further integrated into weekly monitoring activities, with trained quality control specialists listening to portions of roughly 1,000 interviews per field period from across all interview modes. These reviews were used to reinforce positive interviewing behaviors and techniques; in addition, listening to CARI gave field supervisors direct exposure to interviewing behaviors that needed to be addressed. In some cases, CARI recording results were such that interviewers were instructed to stop working until they could receive some retraining, including administering a practice interview to their field supervisor.

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4.2 Data Collection Results: Interviewing

Table 4.2 provides an overview of the data collection results for Panels 23 through 29, showing sample sizes, average interviewer hours per completed interview, and response rates. Table 4.3 shows the final response rates a second time, reformatted to facilitate Round-by-Round comparisons across Panels and years. In addition to the main Panel Rounds, both tables display the extended Panel Round data for Panels 23 and 24.

Of the data collection Rounds conducted in 2024, the response rates for Rounds 1-3 showed a moderate decrease from 2023 while exhibiting a slight increase in Rounds 4-5. While response rates have not returned to pre-pandemic levels despite a return to in-person interviews, they have continued to rebound. Hours per complete continue to increase higher than pre-pandemic for Round 1, averaging almost 15 hours.

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Table 4.4 illustrates the mode of data collection for each of the 2024 data collection Rounds. CAVI was offered as the primary interview mode for Round 5, followed by in-person and telephone where necessary. For all other Rounds, the primary mode was in-person with CAVI as the secondary mode followed by telephone.

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4.2.1 Components of Response and Nonresponse

Table 4.5 summarizes components of nonresponse associated with Round 1 households by Panel beginning in 2019. Prior to 2020, the components of nonresponse remained relatively stable. Starting in 2020, the “refusal” and “other nonresponse” categories have shown a significant increase. Increases and decreases in the percentage of refusals align closely with corresponding decreases and increases in the completion rate.

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Tables 4.6 through 4.13 summarize results for additional aspects of the 2024 data collection. Because Round 1 is the most difficult of all the Rounds, the presentation focuses primarily on Panel 29, Round 1.

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4.2.2 NHIS Completion Status

Each year, the MEPS sample includes a number of households classified in the NHIS as “partial completes,” in which the interviewer was able to complete part, but not all, of the full NHIS interview. The MEPS experience has been that for many of these partial complete NHIS cases, the difficulty experienced by the NHIS interviewer carries over to the MEPS interview�the MEPS response rate for the NHIS partial completes is substantially lower than for the NHIS completes. As noted in Chapter 1, for the 2024 sample, AHRQ repeated the step taken in most years since 2012 of sampling the NHIS partial completes in the “White/other” category at a lower rate than the NHIS completes.

The upper portion of Table 4.6 shows the proportion of partial completes in the sample over recent years. Across all domains, there was a significant drop in the proportion of the sample classified as partial complete in 2020 from all previous years shown on the table. Since then, the proportion of partial completes has increased. The proportion in 2024 is above the levels for the previous five years. The lower portion of the table shows the persistent and substantial difference in response rate between these two components of the sample. Prior to 2020, among the cases originally delivered from the NHIS (that is, with new reporting units discovered during the MEPS interviewing excluded from the counts), the response rate for the NHIS partial completes averaged around 13 percentage points fewer than that for the NHIS completes. In 2024, there was a 19.6 percent difference in response rate for NHIS partial cases.

Note: Figures shown are based on original NHIS sample and exclude reporting units added to the sample as “splits” and “students.”

* 2022 Panel 27, Round 1 original NHIS Sample (N) has been updated.

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4.2.3 Sample Domain

Table 4.7 breaks out response information for the NHIS completes and partial completes by sample domain categories for Panel 29. Table 4.7, unlike Table 4.6, does include reporting units added to the sample during Round 1 data collection; it shows the differential in response rates between the NHIS partial completes and full completes persisting across all of the domains. NHIS partial completes responded at a lower rate in all domains. Within the individual domains, the difference between the response rate for the NHIS completes and the NHIS partial completes was greatest for the White/other domain�26.0 percentage points.

Note: Includes reporting units added to sample as “splits” and “students” from original NHIS households, which were given the same “complete” or “partial complete” designation as the original household.

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Table 4.8 (shown on the next page) further breaks out response information for Panel 29 by interview mode.

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4.2.4 Refusals and Refusal Conversion

Table 4.9 summarizes the results of refusal conversion efforts by Panel. For Panel 29, the rate of “ever refused” RUs increased to 37.4 percent, below its highest level in Panel 26 and Panel 27.

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4.2.5 Tracing and Locating

Table 4.10 shows results of locating efforts for households that required tracking during the Round 1 field period by Panel. The percentage of households that required some tracing in 2024 (9.7%) dropped 0.5 percent from 2023 and saw its lowest rate in many years; the final rate of households that were not located after tracing efforts was 2.8 percent.

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4.2.6 Interview Length

Table 4.11 shows the mean length (in minutes) for interviews conducted without interruption in a single session in Panels 23 through 29. There were a larger number of telephone interviews in 2020 and 2021 due to the pandemic shutdown. These took longer as interviewers had to read the show cards aloud, thus adding time to the interview. Starting in 2022 (with Panel 27 Round 1, Panel 26 Round 3, and Panel 25 Round 5), interview time was reduced. The reduction is largely attributable to the introduction of electronic signature and DocuSign for AFs. In most cases, interviewers no longer have the burden of preparing paper AFs for household member signature.

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Table 4.12 shows the mean length (in minutes) by mode for interviews conducted without interruption in a single session. While CAVI interviews tend to be slightly longer, some of this time is accounted for by the equipment setup and procedures necessary to conduct a Zoom interview.

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4.2.7 Mean Contact Attempts Per Case

Table 4.13 shows mean contact attempts, by mode and NHIS completion status, for all cases in Round 1 of Panels 27 through 29. Overall contact attempts are comparable across all three years, though NHIS partial cases require more contacts.

* RUs=reporting units; CAVI=computer-assisted video interviewing

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4.3 Data Collection Results: Authorization Form Signing Rates

During the Respondent Forms section of the MEPS CAPI interview, interviewers are prompted to ask respondents to sign the AFs needed to conduct the Medical Provider Component of MEPS. AFs are requested for each unique person-provider pair identified during the interview as a source of care for a key member of the household. Medical provider AFs are requested for physicians seen in an office-based setting; for inpatient, outpatient, or emergency room care received in a hospital; for care received from a home health agency; for telehealth; and for certain stays in long-term-care institutions. Pharmacy AFs are requested for each pharmacy from which a household member obtained prescription medicines.

There are three modes by which authorization forms can be signed. Respondents who are available at the time of the in-person interview may sign their forms electronically on the interviewer’s laptop. If a respondent is not available or not willing to sign at the time of the in-person interview, or if the interview is being conducted by CAVI or telephone, the respondent may be sent a link via text or email to sign their forms electronically in DocuSign. AFs may be signed on paper if a respondent is not available to sign on the laptop and does not have a cellphone or email for DocuSign, if the respondent requests paper, or if the signer is outside the RU.

Table 4.14 shows Round-by-Round signing rates for the medical provider AFs for Panels 22 through 29. Prior to 2022, all authorization forms were paper. Starting with the Rounds fielded in 2022, the rates are shown for each signature mode and combined across all modes. In 2024 the signing rate for paper AFs dropped in round 3, but the combined signing rate stayed about the same, or even increased slightly due to a higher signature rate for DocuSign AFs. In round 1, the rate for all modes increased. In round 2, the signing rate overall slightly decreased.

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Calculation of the Round-by-Round collection rate for the medical provider AFs is based on all forms requested during a Round. For later Rounds (that is, Rounds after Round 1), this includes forms fielded but not signed in an earlier Round (nonresponse) as well as forms that were signed in an earlier Round but rendered obsolete because the person had another health event with the provider after the date on which the original form was signed.

Table 4.15 shows signing rates for pharmacy AFs for Panels 22 through 29. Pharmacy AFs are requested starting in Round 2, with follow-up for nonresponse in subsequent Rounds similar to that for medical provider AFs. As with the medical provider authorizations forms, the signature rate for paper AFs decreased in rounds 3, 4, and 5, but the combined signature rate increased or stayed the same due to an increase in the signature rate for DocuSign AFs. Signature mode continues to shift away from paper to eSignature and DocuSign.

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4.4 Data Collection Results: Self-Administered Questionnaire (SAQ), Diabetes Care Supplement (DCS), and Collection Rates

SAQs are requested from key adult household members in Rounds 2 and 4. Forms that are not collected in Rounds 2 and 4 are requested again in Rounds 3 and 5. In 2024, the follow-up in Rounds 3 and 5 was paper only, however, for the initial request in Rounds 2 and 4, we continued to offer multimode (web and paper) collection for SAQs. Invitations to complete the SAQ on the web were included with the advance mailing, giving household members the opportunity to complete SAQs prior to their household interview. During the CAPI interview, interviewers followed-up with eligible household members who had not yet completed the web SAQ. Paper SAQs were offered during the interview only if the household member did not provide an email address and/or cell phone number to which a link to the web SAQ could be sent. Everyone who did not complete their SAQ within a certain time frame from when the household interview was complete was sent a non-response mailing that included a paper SAQ. Table 4.16 shows the SAQ response rates, including both the Round-specific rates and the combined rates after the follow-up Round was completed. This is shown by survey mode for the SAQs requested starting in 2023.

Response rates increased significantly from 2023 to 2024, likely due to the new contact protocol for web SAQs and the additional paper follow-up for web non-response. The rate for Round 2 went from 45.2 percent to 55.1 percent and in Round 4 it went from 43.4 percent to 52.1 percent.

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In Rounds 3 and 5, key adult household members who have been diagnosed with diabetes were asked to complete a short questionnaire called the DCS. Forms not completed for pickup at the time of the interviewer’s visit were followed up on by telephone in the latter stages of Rounds 3 and 5, but unlike the SAQ, there was no follow-up in the subsequent Round for forms not collected in the Round when first requested. Response rates for the DCS for Panels 21 through 28 are shown in Table 4.17. In 2024, the number of DCSs requested increased and the response rate remained the same for Round 5, but increased 6 percentage points in Round 3.

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4.5 Quality Control

Interviewer performance was monitored through validation case review using GPS, CARI, and telephone and mail validation. The purpose of validation was to verify that the correct individual was contacted for the interview and that the interview was conducted according to MEPS-approved procedures.

Generally, all completed cases were validated by first examining the GPS data stored and encrypted on the laptop and through the MFOS app on the project-issued iPhone. If the case could not be properly validated due to missing data, or the GPS information did not match the respondent address or another documented location at the time of the interview, the case was then reviewed in the CARI system. If a case could not be validated in CARI due to poor quality or missing CARI data, the case was referred for telephone validation. All interviews completed in less than 30 minutes were also referred for telephone validation. Finally, for cases assigned to telephone validation, if the household could not be reached, a validation questionnaire was mailed with a return envelope.

In both the spring and fall Rounds of 2024, over 96 percent of completed cases were validated. In the spring Rounds, cases were validated using GPS data and by CARI at about the same rate. In the fall Rounds, cases were validated using GPS data at a much higher rate due to a higher proportion of in-person interviews in the fall, as opposed to CAVI or telephone interviews. CAVI and telephone interviews cannot be validated using GPS data, so in these situations the CARI system is used to validate. A small percentage (5% in the spring and 6% in the fall) were validated by phone, and less than .5 percent of cases were validated by mail.

In addition to validation, a percentage of all interviews are reviewed in CARI by Quality Control Staff to ensure that protocols are closely followed. During the review process, each case is assigned an overall score on a five-point scale from Excellent to Poor. When a case receives an overall score of Fair or Poor, the FI receives a rapid feedback session that provides retraining on general interviewing techniques as well as project specific procedures. After retraining, the next case is coded and a higher percentage of that interviewer’s subsequent cases are manually reviewed. Interviewers who do not improve are placed on formal action plans and ultimately released if they do not show marked improvement. Interviewers who receive an overall score of Excellent, Very Good or Good receive feedback via an email with any applicable notes.

In addition to validating cases, MEPS field supervisors and managers conduct observations as part of a comprehensive mentoring process. Generally, MEPS uses technical solutions in place of in-person observations; however, there are specific needs met by specialized observation. As much as possible, observations are conducted in the early weeks of data collection so that problems can be detected and corrected as quickly as possible, and interviewers are given feedback on ways to improve specific interviewing skills. While CARI offers a high-quality portal for evaluating interviewers on question administration, observations are still a critical tool, particularly of newly hired staff. Compared with the observation process, CARI and other report mechanisms do not allow for assessment of the full range of interviewer skills, including respondent contact, trip planning, gaining cooperation, and interviewer-respondent interactions. In addition, the observer serves as an on-site resource in situations where remedial training is necessary. Observation forms are processed and reviewed at the home office to determine the need for individual and field-wide follow-up on specific skills.

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4.6 Security Incidents

To comply with the requirement of reporting incidents involving loss or theft of hard-copy materials with a respondent’s personally identifiable information (PII) or laptops, field staff continued to use an automated Initial Loss Reporting System (ILRS) to report confirmed incidents. Incidents were entered in the MEPS Help Desk Incident Tracking System, investigated, and were then closed upon resolution. Results were recorded in an annual MEPS PII log. A security incident report was submitted to the Westat Institutional Review Board (IRB) for each confirmed incident.

In 2024, there was one confirmed laptop and one confirmed iPhone loss. The password-protected laptops were shut down at the time of the loss. Since MEPS laptops are full-disk encrypted, respondent identity was not at risk. Over the course of the year, additional iPhones were reported to the MEPS Help Desk as lost but were then found by the interviewer using utilities to track the last GPS point. The MEPS iPhones are also password-protected, and all MEPS contents can be deleted through remote management when the phone is turned on. Interviewers were counseled about keeping MEPS equipment secure at all times.

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5. Home Office Support of Field Activities

The home office supports the data collection effort in several important ways. This support can be described in two phases: One phase of activity supports the launch of each new Round of data collection; another phase supports the field operation while data collection is in progress. These two phases of activity are described in this chapter.

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5.1 Preparation for Field Activities

Prior to the start of data collection for each period, interviewers connected remotely to the home office to download the CAPI software update for the upcoming Rounds and received a home study training package to prepare them for interviewing. Field interviewers also received a replenishment of supplies at the start of the Rounds.

Advance mailings to all respondent households were prepared and mailed by the home office staff prior to the start of data collection. Addresses were first standardized and sent through the National Change of Address (NCOA) database to obtain the most current addresses for mailing. SAQs requested in fall 2023 that were not completed were included in the advance mailing for Round 3 and Round 5 cases in the spring 2024 advance mailing. Any mail returned as undeliverable was recorded, and the appropriate supervisor was notified. Requests to re-mail the Round 1 advance package to households who reported not receiving it were prepared and mailed by home office staff.

Supervisors received a Supervisor Assignment Log, listing all of the cases to be released in their region, for each wave of cases to use to assign cases to their interviewers. They entered the ID of the interviewer assigned to each case and sent the log back to the home office. The logs with assignments were then used to make the electronic assignments in the AFOS. Cases were then available to be picked up upon transmission by the assigned field interviewer on the day data collection began for the Round.

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5.2 Support During Data Collection

Respondent Contacts. Respondent contacts are an important component of home office support for the MEPS data collection effort. Printed materials mailed to respondents contain an email address and toll-free telephone number that respondents can use to contact the project representative with questions and requests to make or to cancel interview appointments�respondents also could choose not to participate in the study. Home office staff received and initiated the response to all respondent contacts. They forwarded information received from respondent calls to the field supervisors, who initiated the appropriate follow-up and informed the home office of the results of their follow-up within 24 hours of notification. Table 5.1 shows the number and percentage of RUs that made calls to the respondent hotline in the spring and fall Rounds of 2020-2024. The percentage of households that called the hotline continued to drop for the spring rounds in 2024, but increased slightly in the fall rounds.

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Table 5.2 shows the number and types of calls received on the respondent hotline during 2023 and 2024. As in prior years, a substantial portion of the Round 1 calls were for refusals, with a significant increase in the rate of calls for refusals over Round 1 in 2023. There was also an increase of over six percent in the number of calls from respondents requesting an appointment, year to year 2023-2024. Over the same period there was a 10 percent decreased in respondents calling that were willing to participate and an increase in the number calling to refuse. For later rounds, the rate by calls classification remained more steady.

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Monitoring Production. Home office staff monitored production, cost, and data quality, and provided reports and feedback to field managers and supervisors for review and follow-up. Reports were generated weekly and distributed to AHRQ, showing weekly and cumulative field production data, response rates, and costs. AFOS and use of the dashboard increased our capabilities to monitor production and cost more effectively.

Home Office Support. Refusal letters were generated and mailed by home office staff as requested by the field. Home office staff also responded to supply requests from the field, replenishing interviewer and supervisor stocks of materials, including items like project pamphlets and incentive debit cards, as needed.

Receipt Control. As interviewers completed cases, they transmitted the data electronically and shipped any hard-copy documents to the home office receipt operation. Interviewers shipped all hard-copy material containing PII via FedEx, which facilitates tracking of late or lost shipments. When preparing a shipment to the home office receipt department, interviewers used the Ship to Receipt module in AFOS to indicate exactly what materials were included in the package and recorded the FedEx tracking number. This information was sent directly to the receipt control system so it was known what materials were expected. For interviews completed by phone or CAVI, and for which pickup of hard-copy documents could not be arranged, interviewers provided a BRE for the respondent to send their documents directly to the home office. AFs signed electronically, either on the laptop or in DocuSign, were uploaded to a secure server to be accessed for receipt. Paper AFs were scanned and uploaded to the secure server, then receipt staff review for accuracy. When a problem was found in an AF, the problem was documented and feedback was sent to the field supervisor to review with the interviewer. All self-administered questionnaires, including SAQs/preventive care self-administered questionnaires (PSAQs) and DCSs, were receipted and sent out for TeleForm scanning.

Helpdesk Support. The MEPS CAPI Helpdesk continued to provide technical support for field interviewing activities during 2024. Helpdesk staff were available 7 days a week to help field staff resolve CAPI, field management system, transmission, laptop, and iPhone problems. Incoming calls were documented for follow-up, as needed, to resolve individual issues and to identify issues reported by multiple interviewers. The MEPS CAPI Helpdesk coordinated tracking and shipping of all field laptops, field laptop assignments, and laptop and phone repairs.

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6. Data Processing and Data Delivery

This chapter briefly describes the activities that supported Westat’s data delivery work during the year and identifies the principal files related to data year 2022, delivered in 2024.

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6.1 Processing to Support Data Delivery

6.1.1 Schedules for Data Delivery

Adhering to the schedule for delivery of the key MEPS public-use files is of paramount importance to the project. Throughout 2024, data processing activities to support the major file deliveries for the year proceeded simultaneously along several different delivery paths, with activity focused separately on each of the Panels for the annual full-year files. As in past years, the project used a set of comprehensive data delivery schedules to guide management of the effort. The schedules integrate key dates for the data collection, data capture, coding, editing and imputation, weights construction, and documentation production tasks. These schedules provide a framework for assessing the potential impact of proposed changes at the start of each processing cycle and for coordinating the succession of processes that comprise the delivery effort.

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6.1.2 Data Quality Control System

The data quality control (DQC) system consists of both a consolidated database that preserves data as returned from the field and a DQC-specific database that shows the current values of data following any required updates. DQC technicians access the data through a secure portal.

Technicians review and edit the data using the Blaise database model that is used in the field for data collection. All DQC work occurs at a “case” level. The DQC system automatically creates a unique “issue” for each instance of text entered as a comment and includes the comment category selected by the field interviewer associated with the text entry. As cases are loaded into DQC, each comment and category are checked by a natural language processing (NLP) algorithm that identifies the most likely category. During processing, data technicians have the opportunity to accept or update this category. Technicians then follow standardized procedures for data review and editing based on the comment category.

The DQC system also runs a series of programmatic checks and assigns a new “issue” for each instance that triggers a consistency or edit check. These checks are designed to ensure that data changed during editing conform fully to the rules of the CAPI instrument before the data are released. In addition, issues are, on rare occasion, added manually to individual cases by DQC staff from MEPS Help Desk reports, such as when a name or email address is discovered to be misspelled after completion of the interview; these issues are included among the number of cases with at least one interviewer comment. During spring 2024, 12 percent of cases received from the field included a comment (Table 6.1). Cases with any issue, a field comment, or a consistency check totaled 29.8 percent in spring 2024. For fall 2024, 15.1 percent of cases received from the field included a comment, while cases with any issue totaled 30.6 percent.

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Field interviewers must select 1 of 10 categories for each comment text string. After selecting a category, CAPI provides category-specific guidance on information to include in the comment (e.g., RU member name, event date). They receive training to help identify the most meaningful category and avoid overuse of the category “Other.” Table 6.2 shows the number of comments made in each category as assigned by the NLP algorithm and confirmed by the data technicians.

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6.1.3 Transformation

Transformation is the process of extracting data from the Blaise data models optimized for data collection and writing them to the data exchange format (Dex) required by the data delivery teams. The transformation has two logical activities: First is transforming the structure of the data from data collection to Dex and then transforming the format of the data from Blaise to Oracle. The resulting data, now stored in Oracle using the Dex structure, serves as input to the analytic editing, variable construction, public-use files (PUFs), and other file deliveries. The goal is to dislocate the delivery activities as little as possible in order to provide data of the highest quality as efficiently as possible.

As shown in Figure 6.1, data transformation has four distinct layers. The metadata layer contains all the variable definitions�including names, tables, or segments or blocks�and transformation logic, sometimes known as “plain-language transformation specifications.” The analytic group leads at Westat are typically responsible for the metadata and the transformation logic.

Figure 6.1. Blaise to Dex transformation

Note: DEX=data exchange format; DQC=data quality control; PUFs=public-use files

Based on the metadata, two specifications are developed. The first describes the Dex structure using a formal schema, which is expressed as a set of SQL statements to create the empty Oracle Dex database. The second specification is the detailed transformation specification. Each variable is assigned to a set of similar variables called a “transformation class.” A unique transformation class is defined by the information needed to specify the transformation. For instance, some variables simply need to be copied to an appropriate location in the Dex. These are known as passthrough variables and belong to the “passthrough” class. “Code All That Apply” variables are transformed based on the value(s) selected by the interviewer, so the specification requires an additional Dex variable for each possible value. “Code All That Apply” is another transformation class.

The third layer is the transformation (or programming) layer. Using the specifications just described, the data are read from the Blaise database in the data collection structure, the transformation logic is applied, and a data file for each Dex table is written. Next, the format is transformed from the Blaise format to Oracle, writing to the single-round database (SRD). The single-round structure is necessary because the data collection instrument does not contain all data for all Rounds for a given case; rather, only the data required to field the case in that specific Round are included. The SRD data are then merged into the existing data, yielding a cumulative multi-round database (MRD).

The final layer relates the different databases to selected key deliverables. This layer is intentionally general. For example, while the MRD is the source for the PUF deliveries, there are many additional steps to edit the data, construct variables, and deliver a data file and codebook.

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6.1.4 TeleForm/Data Editing of Scanned Forms

TeleForm, a commercial off-the-shelf software system for intelligent data capture and image processing, was used in 2024 to capture data collected in the DCS and the SAQ, as well as an SAQ focused on cancer (CSAQ). TeleForm software reads the form image files and extracts data according to the project specifications. Supporting software checks the data for conformity with project specifications and flags data values that violate the validation rules for review and resolution.

With the incorporation of web SAQ data collection, it is necessary to harmonize both the metadata and the data across the different data collection modes. Harmonization begins in the development of the questionnaires to standardize metadata assignment and skip patterns. Incorporating harmonization before fielding decreases the level of effort to fully harmonize post data collection.

Hardcopy data collection allows the respondent more flexibility in answering questions, e.g., providing more than one response to a code-one question and not complying with the flow of the questionnaire. It is necessary to apply missing value recoding (MVR) across the modes of data collection and enforce skip patterns in the data so the data patterns across modes are identical. Once finished, the harmonized data enter the remaining data processing stream as a single data entity.

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6.1.5 Coding

Coding refers to the process of converting data items collected in text format to prespecified numeric codes. For the MEPS-HC, five types of information require coding:

• Medical conditions;
  
  
• Prescribed medicines;
  
  
• Source of payment for medical events and prescriptions;
  
  
• Industry and occupation; and
  
  
• Geographic identifiers.

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6.1.5.1 Medical Conditions and Prescribed Medicine Coding

In 2024, coding was performed on the medical conditions and prescribed medicine text strings reported by household respondents for calendar year 2023. An automated system enabled coders to easily search for and assign the appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code (for conditions) or Generic Product Identifier (GPI) code (for medicines). The system supports the verifier’s review of all codes and, as needed, correction of the coder’s initial decision. For the prescribed medicine coding, a pharmacist provided a further review of text strings questioned by the verifier, uncodable text strings, foreign medicines, and compound drugs. All coding actions were tracked in the systems, and error rates were calculated weekly. Both the condition and prescribed medicine coding efforts were staffed by three coders.

Medical conditions text strings for data year 2023 were coded to include the greatest specificity indicated by the text string. The fully specified ICD-10 code is needed to accurately match to the Clinical Classification Software Refined (CCSR) diagnosis codes. A total of 2,693 unique strings were manually coded, and the authority table was constructed with AHRQ-approved code assignments. The overall error rate for coders was 2.0 percent, at the contractual error rate goal of 2 percent.

Prescription medicine text strings for data year 2023 were coded to the set of GPI codes, associated with the Master Drug Data Base (MDDB) maintained by Medi-Span, a part of Wolters Kluwer. The codes characterize medicines by therapeutic class, form, and dosage. To augment the assignment of codes to less specified and ambiguous text strings, AHRQ developed procedures for assigning partial GPI codes and higher level drug categories that were implemented in 2017 and continued through subsequent coding cycles.

AHRQ also developed a set of exact and inexact matching programs to reduce the number of prescribed medicine strings sent for manual coding. Westat’s implementation of these matching programs reduces the number of prescribed medicine text strings sent for manual coding by approximately 50 percent each year. The matching programs are reviewed and approved each year. A total of 2,172 strings were manually coded from the 2023 data year.

In a process similar to condition text strings, the prescription medicine text strings undergo two Rounds of deduplication to identify the unique strings to be coded. AHRQ’s exact and inexact matching programs are then run to further reduce the number of strings to be coded. In the spring of 2022, the prescribed medicine pick list and search tool was integrated into the CAPI instrument, which impacted the number of strings that need manually coding in 2024. The overall coding error rate (across all coders) was less than 1 percent, which is lower than the contractual goal of 2 percent. As with conditions, all prescription text strings/codes were reviewed by a verifier, with additional review of selected strings provided by a pharmacist.

6.1.5.2 Source of Payment Coding

Source of payment (SOP) information is collected in both the household and the medical provider components. In the HC charge payment section of the CAPI instrument, the names of the sources of payment are collected in three places: when the bill was paid by a source identified in response to a direct question about payment (REIMNAM); when the bill was sent to a source other than the respondent and the respondent names that source (WHOBILL1); and in response to a question about a direct payment source for prescription medicines (SRCNAME). The responses are coded to one of the sources of payment options in which healthcare expenditures are reported in the MEPS PUFs. These payment sources include:

• Out of pocket;
  
  
• Medicare;
  
  
• Medicaid;
  
  
• Private health insurance;
  
  
• Veterans Administration;
  
  
• TRICARE;
  
  
• Other Federal;
  
  
• Other state and local;
  
  
• Workers’ compensation;
  
  
• Uncollected liability;
  
  
• Indian Health Service;
  
  
• Contractual allowance; and
  
  
• Charity or free care.

The SOP Coding Guidelines is a manual updated each year before the start of the annual coding cycle, submitted for AHRQ approval, and distributed to the coders. Health insurance show cards and data from the health insurance plan file for CAPI are available to coders as resource materials. Since the MPC of MEPS uses the same set of SOP codes as the Household Component, coding rules and decisions are coordinated with the MPC contractor (RTI) to ensure consistency in the coding. Before the start of the coding cycle, Westat compares RTI’s authority tables with its own to identify any inconsistencies. AHRQ adjudicates any inconsistencies to ensure the authority tables from each contractor are aligned.

Each year, the SOP text strings extracted from the reference year data are matched to a historical file of previously coded SOP text strings to create a file of matched strings with suggested or “matched” codes. These match-coded strings are reviewed by coders and verified or modified as needed. This review is required because insurance companies change their product lines and coverage offerings very frequently, and as a result, the SOP code for a given text string (e.g., the name of an insurance company or plan) can change from year to year. For example, from one year to the next an insurer or insurance product may participate in or drop out of state exchanges; may offer Medicare Part D or dental or vision insurance, or may drop it; may add Medicare Advantage plans in addition to Medicaid health maintenance organizations (HMO)s; or may gain or lose state contracts as Medicaid service providers. As a result of these changes, the appropriate code for a company or specific plan may also change from year to year. Strings that do not match to a string in the history table are researched and have an appropriate SOP code assigned by coding staff.

SOP coding during 2024 was for the payment sources reported for 2023 events. For cases when the bill was paid by a source identified in response to a direct question about payment (REIMNAM), a total of 1,629 previously coded sources of payment text strings were reviewed and updated as needed. After deduplication of the strings reported for 2023, coders reviewed and coded 1,543 strings. If the bill was sent to a source other than the respondent and the respondent names that source (WHOBILL1), coders reviewed and coded 3,083 strings. For text strings reported as direct payers for prescription medicine (SRCNAME), 410 new text strings were reviewed and coded by coders.

6.1.5.3 Industry and Occupation Coding

Industry and occupation coding is performed for MEPS by the Census Bureau using the U.S. Census Bureau’s Demographic Surveys Division’s computer-assisted industry and occupation (I&O) codes, which can be cross-walked to the 2017 North American Industrial Classification System (NAICS) and the 2018 Standard Occupational Classifications (SOC) system. The codes characterize the jobs reported by household respondents and are released annually on the full-year (FY) JOBS file. During 2024, 16,848 jobs were coded for the 2023 JOBS file.

6.1.5.4 Geographic Coding

The Westat Geographic Information Systems (GIS) division geocodes household addresses, assigning the latitude and longitude coordinates as well as other variables such as county and state Federal Information Processing Standards (FIPS) codes, Metropolitan Statistical Area (MSA) status, Designated Market Area, Census Place, and county. RU-level data are expanded to the person level and delivered to AHRQ as part of the set of “master files” sent yearly. These data are not included in a PUF, but some variables are used for the FY weights processing.

During the calendar year 2024 coding cycle, 13,426 unique address records for full-year reporting units were processed.

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6.2 Data Delivery

The primary objective of MEPS is to produce a series of data files for public release each calendar year. The inter-round processing, editing, and variable construction tasks all serve to prepare these PUFs. Each file addresses one or more aspects of the U.S. civilian noninstitutional population’s access to, use of, and payments for healthcare.

The Oracle system has a separate database for each data year. The MEPS 2024 database developed in fall of 2024 contains Panels 28 and 29. The bulk of data year 2024 will occur in 2025. The MEPS 2023 database fully developed in spring of 2024 contains Panels 27 and 28. Editing activities and much of the variable construction for data year 2023 occurred in 2024 and will continue into 2025. Finally, the MEPS 2022 database containing Panels 24, 26, and 27 supported PUF and other internal use deliveries that occurred in 2024.

After the data are in the Oracle delivery database, each analytical team performs basic edit checks on the data to begin the process. These edits ensure the data conform to the CAPI instrument’s flow as well as to AHRQ’s analytical needs. These edits can be run in SAS, using SAS datasets extracted from the delivery database, or in SQL, directly on the delivery database. Problems identified through the basic edits process may require updates to the data. If updating is required, these updates may be accomplished in one of two ways:

• Programmatic updates can correct problems affecting a large volume of cases that fail a basic edit.
  
  
• Manual updates can be set up with audit trails maintained to correct data anomalies.

Once all the edits have been completed for an analytical team, and quality control (QC) frequencies and univariates have been approved, notification is sent to all other analytical teams so that work can be coordinated in those areas.

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6.2.1 Variable Construction

Analytical groups at AHRQ work with Westat analysts to define the variables of interest for inclusion on the PUF and other key data deliveries. Documentation about individual PUFs is available on the MEPS website: Medical Expenditure Panel Survey Download Data Files. Variables are named according to standard naming conventions, and once the list is approved, descriptive specifications are written to define each variable and to provide detailed information for programming.

Specifications are written at two levels. The high-level specification is a descriptive specification intended to document the concept of the variable and provide high-level information regarding the variable construction requirements. The detailed-level specifications contain the details required to develop programming code for building the variables. Specifications are written and sent to AHRQ for approval. Once approval is received for the specification, program development can proceed for that variable. Specifications guide programming development, and once programs have been written, code reviewers compare newly developed code against specifications to identify problems in either code or specifications. This program development process includes a number of steps and checkpoints to ensure that all new programs meet all specification requirements:

• Review approved high- and detailed-level specifications
  
  
• Write programs for each specification using SAS or SQL
  
  
• Test all programmed code for accuracy
  
  
• Conduct detailed code reviews to review specifications and code
  
  
• Test code on SAS production files or Oracle database without committing
  
  
• Construct variables either in SAS (and either load variables to Oracle or continue development in SAS, depending on the file) or directly in the Oracle production database
  
  
• Review frequencies and cross-tabulations for accuracy

This model is followed for the development of all new programs required for data delivery. For mature programs that are reused in subsequent deliveries with only minor modifications, the process is appropriately streamlined to ensure both accuracy and efficiency on all programs.

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6.2.2 File Deliveries

6.2.2.1 Public-Use File Deliveries

The principal files delivered during calendar year 2024 are listed below:

• Full-Year 2022 Population Characteristics file
  
  
• Full-Year 2022 Use and Expenditure file
  
  
• Full-Year 2022 Expenditure Event files for events included in the MPC data collection including hospital inpatient, outpatient, and emergency room events; office-based physician visits; and home health agency events
  
  
• Full-Year 2022 Expenditure Event files for events not included in the MPC data collection, including dental events, office-based nonphysician events, and other medical expenses
  
  
• Full-Year 2022 Prescribed Medicines Expenditure file
  
  
• Full-Year 2022 Medical Conditions file
  
  
• Full-Year 2022 JOBS file
  
  
• 2022 Food Security file representing the time period of late summer to late fall of 2022
  
  
• Full-Year 2022 Appendix to MEPS Event files
  
  
• Full-Year 2022 Person Round Plan file

6.2.2.2 Ancillary File Deliveries

In addition to the principal data files delivered for public release each year, the project also produces a number of ancillary files for delivery to AHRQ. These include an extensive series of person- and family-level weights, “raw” data files reflecting MEPS data at intermediate stages of capture and editing, and files generated at the end of each Round or as needed to support analysis of both substantive and methodological topics. A comprehensive list of the files delivered during 2024 appears in the appendix.

6.2.2.3 Medical Provider Component (MPC) Files

During each year’s processing cycle, Westat also creates files for the MPC contractor and, in turn, receives data files back from the MPC. As in prior years, Westat provided sample files for the MPC in three waves, with the first two waves delivered while HC data collection was still in progress. In preparing the sample files to be delivered in 2024 for MPC collection of data about 2023 health events, Westat again deduplicated the sample of providers. This process, developed in consultation with AHRQ, was designed to reduce the number of duplicate providers reported from the household data collection.

Late in 2023, following completion of MPC data collection and processing for 2022 events, Westat received the files containing data collected in the MPC with linkages to matching events collected in the MPC with events collected in the HC. In processing at Westat, matched events from the MPC served as the primary source for imputing expenditure variables for the 2022 events. A similar file of prescribed medicines was also delivered to support matching and imputation of expenditures for the prescribed medicines at AHRQ. Timely and well-coordinated data handoffs between Westat and the MPC are critical to the timely delivery of the full-year expenditure files. With each additional year of interaction and cooperation, the handoffs between the MPC and HC have gone more and more smoothly. This vital exchange of files fed into imputation activities that occurred in 2024.

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Appendix A
Comprehensive Tables – Household Survey

* RU-level sample size for this table derived from the field management system counts and operational reports detailing the fielded sample.

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* Figures in the table are weighted to reflect results of the interim nonresponse subsampling procedure implemented in the first Round of Panel 16.

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