MEPS Annual Methodology Report 2022

Deliverable Number: 121D.102
Contract Number:75Q80120D00024
June 30, 2023

Authors
Westat
Westat Reference Number: 2-7-679
Final

Submitted to:
Agency for Healthcare Research and Quality
Center for Financing, Access, and Cost Trends
560 Fishers Lane
Rockville, MD 20850

Submitted by:
Westat
An Employee-Owned Research Corporation^®
1600 Research Boulevard
Rockville, Maryland 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 Changes to CAPI Instrument for 2022
2.3 Testing of the Questionnaire and Interviewer Management System
2.4 Changes to Materials and Procedures for 2022
3. Recruiting and Training
3.1 Field Interviewer Recruiting for 2022
3.2 2022 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
4.3 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
1-1 Initial MEPS sample size (RUs) and number of NHIS PSUs, all panels
1-2 Data collection periods and starting RU-level sample sizes, spring 2018 through fall 2022
1-3 Percentage of NHIS households with partially completed interviews in Panels 4 to 27
1-4 Distribution of Panel 27 sampled RUs by sample domain
2-1 Authorization form methods: Summary and benefits
2-2 Supplements to the CAPI core questionnaire (including hard-copy materials) for 2022
3-1 Staffing for spring field period, 2018–2022
3-2 Spring attrition rate among new and experienced interviewers, 2018–2022
3-3 Fall attrition rate among new and experienced interviewers, 2018–2022
3-4 Annual attrition rate among new and experienced interviewers, 2018–2022
4-1 Data collection schedule and number of weeks per round of data collection, 2022
4-2 Case potential categories for classifying and prioritizing case work, spring 2022
4-3 MEPS-HC data collection results, Panels 21 through 27*
4-4 Response rates by data collection year, 2013–2022
4-5 Completed cases by mode of interviewing for Panels 23 through 27
4-6 Summary of MEPS Round 1 response and nonresponse, 2017–2022 panels
4-7 Summary of MEPS Round 1 response, 2017–2022 panels, by NHIS completion status
4-8 Summary of MEPS Panel 27 Round 1 response rates, by sample domain by NHIS completion status
4-9 Summary of MEPS Panel 27 Round 1 response rates, per interview mode, by sample domain by NHIS completion status
4-10 Summary of MEPS Round 1 results for RUs who ever refused, Panels 21 through 27
4-11 Summary of MEPS Round 1 results for RUs who were ever traced, Panels 21 through 27
4-12 Interview timing comparison, Panels 21 through 27 (mean minutes per interview, single-session interviews)
4-13 Interview timing comparison by interview mode for Panels 23 through 27 (mean minutes per interview, single-session interviews)
4-14 Mean contact attempts by NHIS completion status and interview mode, Round 1 of Panels 25 through 27
4-15 Signing rates for medical provider authorization forms for Panels 20 through 27
4-16 Signing rates for pharmacy authorization forms for Panels 20 through 27
4-17 Results of Self-Administered Questionnaire (SAQ) collection for Panels 21 through 27
4-18 Results of Diabetes Care Supplement (DCS) collection for Panels 19 through 26
5-1 Number and percent of respondents who called the respondent information line, 2018–2022
5-2 Calls to the respondent information line, 2021 and 2022
6-1 2022 cases with comments or data check issues
6-2 Total number of comments by category
A-1 Data collection periods and starting RU-level sample sizes, all panels
A-2 MEPS household survey data collection results, all panels*
A-3 Response rates by data collection year
A-4 Summary of MEPS Round 1 response and nonresponse
A-5 Summary of Round 1 response by NHIS completion status
A-6 Summary of MEPS Round 1 results for all RUs who ever refused
A-7 Summary of MEPS Round 1 results for RUs who were ever traced, Panels 15-27
A-8 Interview timing comparison (mean minutes per interview, single-session interviews)
A-9 Mean contact attempts by NHIS completion status, Round 1
A-10 Signing rates for medical provider authorization forms
A-11 Signing rates for pharmacy authorization forms
A-12 Results of Self-Administered Questionnaire (SAQ) collection*
A-13 Results of Diabetes Care Supplement (DCS) collection*
A-14 Results of patient profile collection
A-15 Calls to respondent information line
A-16 Files delivered during 2022
Figure 6-1 Blaise to Dex transformation

Introduction

The Household Component of the Medical Expenditure Panel Survey (MEPS-HC, Contract 290- 2016-00004I, awarded July 1, 2016, and Contract 75Q80120D00024, awarded July 13, 2020) 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 non-institutionalized 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 2022.

Data are collected for the MEPS-HC through a series of overlapping household panels. Each year a new panel is enrolled for a series of five in-person interviews conducted over a 2½-year period.

Panels 23 and 24, however, have been extended to nine interviews conducted over 4½ years, as described in the section below on changes due to COVID-19. This report describes work performed for all of the panels active during calendar year 2022. Data collection operations in 2022 were for Panel 23, Round 9; Panel 24, Rounds 7 and 8; Panel 25, Round 5; Panel 26, Rounds 3 and 4; and Panel 27, Rounds 1 and 2. Data processing activity focused on delivery of full-year utilization and expenditure files for calendar year 2020.

The report touches lightly on procedures and operations that remained unchanged from prior years, focusing primarily on the results of the 2022 operations and features of the project that were new, changed, or enhanced for 2022. Tables in the body of the text highlight the 2022 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 2022 sample and activities associated with preparing the sample for fielding. Chapters 2 through 5 discuss activities associated with the data collection for 2022: 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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Changes Due to COVID-19

All MEPS Household Component (MEPS-HC) face-to-face interviewing ceased on March 17, 2020, due to the impact of COVID-19 on American life. Data collection switched to the telephone mode, and in 2020 and 2021 a mix of in-person and telephone interviewing was used, depending on the level of the COVID-19 pandemic. In 2022, MEPS added computer-assisted video interviewing (CAVI) as an alternative to telephone interviewing.

MEPS-HC continued several modifications to project systems, processes, and procedures begun in 2020 to respond to the pandemic and added several more to adapt to the ongoing pandemic. Please see the 2020 and 2021 methodology reports for additional details:

Extension of Panels 23 and 24. Anticipating the potential negative impacts of the COVID-19 pandemic on response rates and the number of households that would be included in 2020, 2021, and 2022 data, a decision was made to extend Panel 23 and Panel 24 through nine rounds. The extended panel rounds have been conducted primarily by telephone, with limited in-person interviewing conducted when safe for hard-to-reach or hearing-impaired respondents.

Virtual New Interviewer Training. In 2022 MEPS again trained new interviewers virtually through a blend of asynchronous home study modules and synchronous Zoom sessions. MEPS added a second new hire training in May to the usual January training to ensure sufficient staffing for the three main panels and the two extension panels.

Introduction of CAVI as an Alternative to Telephone. In 2022, MEPS interviews were conducted by three modes: in-person, CAVI, and telephone. Interviewers were given guidance throughout each field period about which modes were appropriate for their cases, and interview modes were closely monitored. CAVI offered the opportunity for interviewers and respondents to both see and hear each other, allow respondents to share images of records, and allow interviewers to display show card images to help respondents select a response. CAVI interviewing started in late spring 2022 but became pervasive in the fall, accounting for over 20 percent of completed interviews. CAVI was offered when respondents were unwilling to have an interviewer in the respondent’s home and for later round cases that had been completed by telephone in 2020 and 2021.

Electronic Authorization Forms. In 2022 MEPS began offering electronic methods for authorization forms (AFs). During in-person interviews, available household members signed on the interviewer’s laptop (using a process hereafter referred to as 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. Collecting electronic signatures provided considerable benefits to the project, most notably reducing burden to both respondents and interviewers, which resulted in a savings of approximately 6 minutes during the computer-assisted personal interviewing (CAPI) interview. Additional benefits included a shorter time span between collection of the signature and receipt and fewer errors on AFs that would otherwise make them unusable.

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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. Beginning in 2020, with the onset of the COVID-19 pandemic, and continuing through 2022, there were concerns of declining response rates as well as challenges in recruiting respondents by telephone. To help maintain the ongoing sample, Panel 23 was extended for a third year of data collection in 2020 and a fourth year in 2021, and Panel 24 was extended for a third year in 2021 and fourth year in 2022.

The sample for the new MEPS panel in 2022, Panel 27, 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 22-26). Specifically, the MEPS household sample was randomly selected from among those that participated in the NHIS during the first three quarters of 2021 and who had been assigned to NHIS Panels 1 and 3, the NHIS panels designated for MEPS.

This chapter describes the 2022 MEPS sample drawn from 2021 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 27 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 27 is based on the number of PSUs associated with MEPS after the 2016 NHIS sample redesign, the sixth 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 mid-year. Normally, during the July-December period, Round 2 of the new Panel and Round 4 of the remaining continuing Panel are fielded.

However, with the extension of Panels 23 and 24 beginning in 2020, additional Rounds were fielded: Round 7 and 9 in the January-June period, with the Panel in Round 9 retiring in mid-year, and Rounds 6 and 8 in the July-December period. Table 1-2 summarizes the combined workload for the January-June and July-December periods from spring 2018 through fall 2022.

Over the years shown in Table 1-2, the combined spring and fall workload has ranged from a low of 36,664 in 2019 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 2022, there were five active Panels in the spring field period and three in the fall field periods. The spring field period still had more cases, with 24,465 cases fielded, while the fall workload had 12,491 RUs, the lowest of the 5 years shown.

* RU-level sample size for this table derived from field management system counts and operational reports detailing 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. 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). Table 1-4 shows the Panel 27 sample distribution by domain.

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* 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 27.

**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 2022 MEPS sample was received from AHRQ and NCHS in three deliveries. The first delivery, containing households sampled from the first and second quarter of the 2021 NHIS, was received on September 10, 2021. Households selected from the third quarter of the NHIS were delivered on November 17, 2021.

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 2022 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

Each year, the project makes a number of changes to the instrument used to collect MEPS-HC data, as well as to the field procedures followed by the interviewers who collect the data. The notable changes made for 2022 are detailed in this chapter.

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2.2 Changes to the CAPI Instrument for 2022

The MEPS-HC CAPI instrument was modernized as part of a technology upgrade launched in spring 2018. For each data collection cycle since then, AHRQ and Westat have worked together to define a set of modifications to the CAPI instrument. Some modifications are new items or new sections, whereas others are updates or fixes to existing items.

For 2022, there was only one notable global change: adding a CAPI hot key (F7) to bring up an electronic version of the English show cards for interviewers to reference or read to their respondents. This change was intended to help improve telephone interview interactions.

Section-specific changes for the 2022 data collection period, both spring and fall, are summarized below.

Start/Restart (ST). The interview mode (in-person, telephone, or CAVI) is now recorded by the interviewer at the start of each interview session in the ST section of CAPI, instead of after the interview is completed in the RU Information Module. Collecting the mode at the beginning of each session allows more than one mode to be recorded when the interview is completed across multiple sessions. Additionally, the RF (Respondent Forms) section of CAPI uses the interview mode to provide tailored instructions regarding the collection of AFs; see below for more information.

Calendar (CA). In response to feedback from computer-assisted recorded interview (CARI) recordings, the Calendar section introduction text was moved to a separate screen prior to the records grid. This change encourages verbatim reading from interviewers.

Date Picker. To simplify training and the user interface of the date picker, the monthly recurrence options were eliminated. Paradata indicated that these options were rarely used. Additionally, the event type listed in the header of the date picker was changed from an acronym to a descriptive label (for example, Telehealth instead of TH) to remind interviewers to add only events of the same type at the date picker. This change was intended to reduce the opportunity for interviewer error. Finally, when the discharge date recorded at the hospital date picker is the same as that person’s reference period end date, a pop-up question confirms whether the RU member is still the hospital. The wording of the question used was revised to help prevent closing a still-in-hospital event in error.

Provider Look-up. A new “AHA” column was added to the provider look-up, indicating facilities that are members of the American Hospital Association (AHA). Interviewers are trained to select the AHA entry when they are having trouble distinguishing between multiple identical (or very similar) search results, after confirming all the relevant details. This should reduce search time for large facilities with many look-up entries. Additionally, a number of common pharmacy retail clinics were added to the provider look-up. Many pharmacy retail clinics have expanded their health care offerings, including vaccinations as well as the diagnosis or treatment of minor injuries and illnesses. This will ideally increase the share of events linked to a provider with an NPI ID.

Condition Look-up. To reduce the number of “Not Specified” or “Location Not Specified” entries that are selected, a new LOCATION probe was added to the condition look-up. For select entries where the location is not specified, the interviewers is prompted to use a standard follow-up probe about the location. The condition look-up was also updated with a small number of additional conditions.

Prescribed Medicine Look-up. In spring 2022, a prescribed medicine look-up was added to CAPI in order to increase data quality while reducing burden. From all prescribed medicine roster screens, interviewers can now search a list of over 2,000 prescribed medicines, including various strength and forms. There are options to select an entry directly from the look-up, edit an entry (for example, to modify the strength or form), or add a manual entry. The prescribed medicine look-up functions similarly to the other CAPI look-ups in that it uses a trigram search method. The look-up also formalizes the probing requirements for prescribed medicines and provides interviewers with common synonyms and acronyms.

Provider Probes (PP). After the first Provider Probe, the reference period is now optional text for all other questions in the series. This helps reduce burden and encourages verbatim reading. A fill that reads “other than what we’ve already talked about” was also added to reduce confusion or duplicate reporting of events by respondents.

Other Medical Expenses (OM). To accommodate alternate payment arrangements, the question about long-term medical equipment purchases was updated to include equipment rentals.

Charge/Payment (CP). To complement the change made in the OM section, questions about charges for long-term medical equipment were updated to also refer to rentals.

COVID-19 (CV). In response to the COVID-19 pandemic, a new section was added in 2021 to initially collect information about delays in care due to the pandemic, and later included questions about COVID-19 vaccination. For spring 2022, the delays in care questions were asked only of continuing panels through December 31, 2021. The COVID-19 vaccination series was also revised to add new question regarding booster shots. In fall 2022, the questions on delays in care due to the pandemic were entirely removed.

Employment (EM) and Related Sections. A few minor changes were made to the employment sections for spring 2022. One change was modifying the approach when a person reports health insurance coverage from both a job and a union. These people are now asked to pick whether the employer or union insurance is primary. Then in the health insurance section, only details about the primary insurance source are collected. This change was made to reduce the amount of time and resources spent on de-duplicating insurance coverage.

Another change was modifying the routing and wording for the question asking whether a job now provides health insurance (RJ80). The question universe now includes continuing jobs where the jobholder initially reports holding partial-round health insurance coverage. This change was made to prevent collecting extraneous or inaccurate data.

Health Insurance (HX) and Related Sections. Show card HX-2 (which displayed an example of each state-specific Medicaid card) was removed, as were callouts at related questions. The remaining HX show cards were renumbered to accommodate this change.

Another update was simplifying the Tricare response categories at all related items (HX125, HX260, PR280). Multiple military health care response options (Tricare Standard, Tricare Prime, and Tricare Extra) were collapsed into a single “Tricare” option. As Tricare plan names and benefits have changed over time, this change was made to simplify the questionnaire and reduce respondent burden.

To reduce interview administration time and burden, at HX130 the definition of Indian Health Service was moved to optional text.

New follow-up unfolding bracket questions were added in both the HX (HX702 and HX704) and OE (OE212 and OE214) sections to capture more detail about policy deductible amount. This change was made to improve annual deductible estimates.

Contacting Module (CM). In spring 2022, MEPS introduced the collection of electronic AFs. To facilitate this effort, a new section called the Contacting Module was added to the CAPI instrument. Most critically for AFs, the CM section collects an email address and cellphone number for each adult household member. This data enables MEPS to send emails and texts to RU members regarding DocuSign AFs.

A large portion of the Closing section was moved to this new CM section. This includes the collection of information to ensure that households can be reached for participation in future rounds, such as the best contact time, proxy information, a mailing address if it’s different from the locating address, a second home address, locating contact, alternate respondent, and plans to move.

In Fall 2022, a slight change was made to the CM section. Instead of asking the respondent if it is okay to text other RU members, we now ask if the cellphone owner is available to talk. If they are, they are directly asked for permission to send text messages to their cellphone.

Respondent Forms (RF). In Spring 2022, MEPS began to offer electronic methods for AFs to streamline the signature process for interviewers as well as signers. Significant changes were needed to the RF section to accommodate the two new signing methods (eSignature and DocuSign), in addition to continuing to offer the paper method. Collecting electronic signatures provided considerable benefits to the project, most notably reducing burden to both respondents and field interviewers, which resulted in a savings of approximately 6 minutes during the CAPI interview. Additional benefits include a shorter timespan between collection of the signature and receipt and fewer errors on AFs. Table 2-1 provides a summary of the three AF methods and their benefits.

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The RF section assigns the signing method based on interview mode and contact information availability. Within an RU, each person may be assigned the same method, or they all may be assigned different methods. After the methods are assigned, the RF section loops on each person to: (1) use the eSignature application, (2) explain the DocuSign invitations that will be sent after the interview is complete, or (3) prepare and complete the paper AFs.

A new eSignature application was specifically designed for completing MEPS AFs. It was integrated into CAPI and launches at the appropriate screen in the RF section, like the date picker or the provider look-up.

For fall 2022, some minor tweaks were made to the RF section and eSignature application based on lessons learned from the spring cycle. These included: enlarged signature boxes on the eSignature application screen; revised instructions for interviews conducted by telephone and CAVI (computer-assisted video interviewing); and more consistent screens for the eSignature and paper methods.

Closing (CL). In 2022, multiple changes were made to the Closing section to accommodate two new procedures: electronic AFs and debit card incentives. While contact information has traditionally been requested in the Closing section, it needed to be collected earlier in the interview so it could be used to determine each person’s appropriate AF signing method during the Respondent Forms section. As a result, most items from the CL section were moved to the new CM section previously described.

MEPS respondent incentives were updated from checks to debit cards, and the delivery of the incentive was moved from the CAPI instrument to the Interviewer Management System (IMS). As a result, multiple changes were made to the Closing section to update wording and remove screens related to preparing and delivering the checks. Additionally, the interviewer now records the interview language in the CL section, instead of the RU Information Module. This ensures the interview language is stored along with the CAPI data and is available immediately for post-collection tasks, such as sending DocuSign invitations.

Supplements to the CAPI Instrument

Table 2-2 shows the supplements for the rounds administered in calendar year 2022. The only notable change was to the Your Health and Your Opinions preventive care self-administered questionnaire (PSAQ). In 2020, the PSAQ was modified to include supplemental items on alcohol and drug use, as well as items on mental health counseling and treatment. The fall 2022 PSAQ retained much of this special content but eliminated items on exact number of days using drugs and alcohol and some of the items related to benefits of counseling and alternative counseling treatments. In their place, the PSAQ included select questions from the “Social and Health Experiences” questionnaire (known internally as the Social Determinants of Health or SDOH SAQ), which had been fielded in 2021. Questions selected were on topics not as well represented in the core MEPS questionnaire, including questions on exercise and financial stability.

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2.3 Testing of the Questionnaire and Interviewer Management System

Testing for the spring 2022 (Rounds 1/3/5/7/9) instrument was conducted between September and December 2021. Testing for the fall 2022 (Rounds 2/4/8) instrument was conducted between March and June 2022. 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 spring 2022 development cycle also included extensive testing related to electronic AFs. This included unit and integrated testing of: revised screens and routing in the CAPI instrument; AF method assignment; the eSignature application; data including the AF array; the Basic Field Operating System (BFOS) AF module; receipt procedures; and DocuSign AFs, including the use of various devices to access and complete the forms.

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2.4 Changes to Materials and Procedures for 2022

The manuals and the materials for the 2022 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.

Instructional Manuals

The field interviewer procedures manual was updated to address changes in field procedures and updates to the Interviewer Management System (IMS).

A new AF manual was prepared that detailed the procedures related to AFs for all three signing methods. Additionally, a new MEPS Computer-Assisted Video Interviewing (CAVI) Operations Manual was developed to fully detail the guidelines for conducting MEPS interviews via this mode. Hard-copy versions of these supplementary manuals were provided to all interviewers during the spring 2022 cycle.

Electronic 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. In 2022, minor revisions were made to the Contacting Information tab in the Face Sheet to align with the revised collection of contact information in the CAPI instrument.

The IMS also contains an RU Information module for documenting operational information to help the next round’s interviewer effectively work each case, an RU Contact module for reporting address and telephone number changes identified prior to the CAPI interview, and the Interviewer Assignment Sheet (IAS), which supports follow-up for AFs and SAQs not completed at the time of the interview. The Authorization Form Log in the IAS was updated to allow for recording follow-up calls related to AFs. Changes were also made to the Current Round Contacting Information tab in the IAS, to align with the revised collection of contact information in the CAPI instrument.

To support the new debit card incentive procedures, a Respondent Payment module was added to the IMS.

Interviewers continued to be equipped with iPhones used for their MEPS work. When changes were made to the laptop IMS, the iPhone mFOS application generally had corresponding changes to match.

New for 2022 was the BFOS Authorization Form Module, used for helping interviewers with their follow-up efforts related to AFs. This module shows when forms are received by receipt control, and it is checked by interviewers prior to making follow-up calls.

Advance Contact and Other Case Materials

All respondent letters, monthly planners, and self-administered questionnaires were updated with the appropriate year references. Furthermore, the Informed Consent, Income Job Aid, Authorization Form Booklet, Record Keeper, and Records Job Aid were redesigned to match the refreshed materials look introduced in 2021.

There were multiple changes to materials related to the new electronic AF collection. A redesigned Authorization Form Booklet addresses the new electronic signing methods. Additionally, interviewers who conduct interviews in Spanish can refer to a new Spanish AF handout. This handout has a Spanish translation of the medical AF on one side and the pharmacy AF on the other. Finally, interviewers received multiple styluses used for signing via the eSignature application on the MEPS laptop.

The MEPSDocs.org website continued to be available to respondents to boost cooperation, ease legitimacy or COVID-19 concerns, and offer recordkeeping tools. In 2022, the Income Job Aid was added to the website. The MEPSDocs website also has links to the show cards in both English and Spanish. These electronic show cards are accessed by interviewers during CAVI interviews (using Zoom to display the show cards), as well as by respondents during telephone interviews.

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3. Recruiting and Training

3.1 Field Interviewer Recruiting for 2022

Overview. For spring 2022 data collection, MEPS attempted to recruit approximately 140 new interviewers across two recruiting periods to join the team of approximately 265 interviewers who were active on MEPS at the start of the 2022 data collection in early January. Our goal was to increase the team for spring data collection to about 400 interviewers.

To put the recruiting and attrition numbers into perspective, Table 3-1 summarizes the MEPS spring data collection staffing for the period of 2018-2022.

Spring 2021 Attrition Staffing - *Note that the total of 147 includes the 36 Interviewers who were not trained until mid-June to shore up fall staffing.

Spring 2022 Attrition Staffing - **Note that the total of 93 new interviewers includes 18 interviewers who were trained mid-May to shore up the spring 2022 data collection staff.

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Recruiting Goals. Based on a projected sample size of approximately 26,000 RUs across the five panels to be fielded for spring 2022 and the likely number of experienced MEPS interviewers available at the end of fall 2021 data collection (about 265), including a MEPS travel team of 10 to 12 members, Westat estimated needing to recruit between 120 and 140 new interviewers for the standard staffing model. The goal was to start data collection with approximately 400 interviewers actively working during the spring 2022 data collection period.

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.

The main recruiting of new field interviewers for 2022 began in late September 2021 and continued until the end of December 2021. Since it was likely that MEPS would continue to complete telephone interviews, at least early in the spring 2022 data collection period, MEPS posted for regular interviewers, telephone/traveling interviewers, and telephone-only interviewers to cast as wide a net as possible for new hires for spring 2022. Westat implemented a COVID vaccination mandate, effective January 2022. In anticipation of difficulties in staffing enough new interviewers during the main recruiting period, MEPS planned to do additional recruiting beginning in early March to have additional new interviewers ready to attend an attrition training in May to supplement the spring 2022 interviewing staff. Recruitment for the attrition training began in early March and ended in late April.

Recruiting Outcomes. During the main recruiting period, 104 candidates accepted job offers. However, with the COVID vaccine mandate that went into effect at the beginning of January 2022, 15 of these candidates were not cleared to work because of noncompliance with the mandate. Of the remaining 89 candidates, 83 of them started training and 75 completed the training. With the addition of these new trainees, the project began 2022 data collection with a total of 350 interviewers.

The goal was to add 50 more interviewers during the short attrition recruiting period. Note that MEPS only posted for in-person interviewers during this additional recruiting period since more of the data collection was transitioning back to in-person interviewing. However, only 28 candidates accepted job offers during this short recruiting period. Two of these candidates were not cleared to work for noncompliance with the COVID vaccine mandate. Of the remaining 26 candidates, 25 of them were expected at training and 18 of them completed the training.

Interviewer Attrition During 2022 Data Collection. During the spring data collection, 38 new interviewers and 32 experienced interviewers were lost to attrition. An additional 13 new interviewers and 25 experienced interviewers were lost during the fall round. Total attrition for the year was 29 percent, a rate more in line with the attrition level of 30 percent during the first year of the pandemic when data collection mode switched from in-person to telephone interviewing. In looking forward to 2023, MEPS plans to expand the interviewing staff so that we can begin data collection with close to 400 interviewers. The breakdown of 2022 interviewer attrition is shown in Tables 3-2 (spring), 3-3 (fall), and 3-4 (total).

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Table 3-2 shows the overall attrition rate during the spring data collection period from 2018 through 2022. Note that the total spring 2022 attrition rate of 18.8 percent is comparable to what MEPS experienced in spring 2019, the year before that pandemic hit and data collection mode changed. The new hire spring attrition rate remains high but has decreased slightly from 40.8 percent to 36.2 percent. In 2022, new interviewers were trained virtually, a factor that makes it much easier for a new hire to quit.

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Table 3-3 shows the overall attrition rate during the fall data collection period from 2018 through 2022. Note that the total fall 2022 attrition rate was 12.9 percent, a decrease from last year when the fall attrition rate was the highest in five years. However, the fall 2022 rate is still higher than the average 8 percent rate of the three prior years.

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The annual attrition rate for 2022 was 29 percent, a decrease of 6.4 percent from 2021 when the annual attrition rate was the highest rate in the past 5 years. The continued high rate of attrition among new hires is likely related to the continuation of the pandemic conditions, namely, a reliance on a high proportion of the interviewing being done by telephone and the virtual training format that has made it much easier for new hires to quit mid-training.

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3.2 2022 Interviewer Training

The overall structure for training new interviewers in 2022 was similar to the structure of the 2021 training to accommodate a remotely administered training due to the COVID-19 pandemic. It began with a home study, followed by a remote training conducted over Zoom for Government in late January 2022, and ending with completion of a two-part, post-classroom home study component. An attrition training was also conducted in May 2022.

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 quizzes 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 remote training, but not so early that their introduction to important study concepts and project terminology would degrade before the remote training. The training added additional practice with the Zoom platform prior to the remote training.

Remote Training. The usual 8½-day training format included the weekend off to attend to asynchronous content that had not been completed and address personal needs that were impacted by the remote approach. Any synchronous content accommodated trainees from the East Coast to the West Coast; therefore, the training day hours were from 12 pm through 5:30 pm EST for synchronous content.

Training sessions used a “block” approach to the training, with each training day consisting of a block of synchronous training and a block of asynchronous training. Trainees had synchronous training for some portion of each training day. Trainees completed required asynchronous blocks prior to the corresponding synchronous blocks.

For the 8½ days of project-specific training, each trainee was assigned to one of six training classrooms (two for the May attrition training) staffed by a primary and support trainer, one or two classroom runners, and a Zoom host. The selection of trainers for the 2022 new hire training was based on several criteria including experience training with the CAPI instrument, overall project knowledge, and prior training experience. Prior to remote training, all training and support staff received a training on the remote platform; the associated technologies; and the content, activities, and procedures associated with remote 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. In addition, full and “mini” mock interviews (or “mocks”) 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 Re-enumeration through Closing, while a “mini” mock relies on preloaded data to allow the training to begin at the desired questionnaire section. For the remote training, the mocks were delivered in one of three ways: demonstration, simulation, and teleconference.

Mock 1 (Round 1) was demonstrated in a synchronous session, with trainers displaying the CAPI screens and trainees reading the questions from the screen and calling out the appropriate keyboard response to the questions.

Mock 2 (Round 3) was posted on the LMS as an interactive CAPI simulation, with respondent answers coded into the simulation. Although the simulation looked and behaved like the CAPI instrument, corrective feedback was given immediately when the trainee coded incorrectly.

Mock 3 (Round 5) was administered via teleconference call led by an experienced trainer with additional support for troubleshooting. The mock was altered to begin in the Calendar section to allow for completion of the interview. The teleconference allowed for additional hands-on CAPI practice for trainees and gave the trainer the opportunity to evaluate trainee performance.

Mini-mocks and materials on the IMS were presented in one of three modes: synchronous training in the virtual classroom, CAPI simulation hosted on the LMS, and independent practice from hard-copy materials to allow for hands-on CAPI/IMS practice.

Dyads paired trainees in a virtual breakout room to conduct an interview with one trainee playing the role of interviewer, and the other using a script to play the respondent. Each dyad pair was observed by a dyad observer, either a field supervisor or other training staff. 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.

The remote 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.

In the past, scripted lab material had been provided to trainers and trainees for in-person lab practice. Often, trainees who wanted additional CAPI practice would take the scripts with them to work on independently. For the remote training, Westat offered some hard-copy scripted materials to all trainees as required independent practice. Additional support was provided as follows:

1. Westat offered “office hours” for trainees to connect by video with experienced MEPS staff who could answer questions and address concerns.
   
   
2. Similar to in-person labs, Westat had a sign-up method (CVENT) for trainees to attend sessions for targeted review of concepts. Westat had the trainee share the screen for trainers to watch. Since the majority of help for trainees during the remote session labs was one-on-one practice, rather than using scripted materials, trainers spoke with the training team lead as well as the trainee themselves to get a feel for where extra practice was needed. The trainer then customized the one-on-one instruction to meet the needs of the trainee.
   
   
3. When a trainer or field management staff identified a trainee as needing one-on-one help, a member of the training floater team was assigned to work with the trainee.

Seventy-five new hires successfully completed the main training, and 18 successfully completed the attrition training.

Bilingual training followed a similar format to in-person training. Bilingual trainees participated in a 4-hour block of training on the last half-day of training. Trainees completed a Round 3 dyad in Spanish. The same format for dyads used in the main training was applied to bilingual training. Trainees divided into breakout rooms to complete the dyad with training staff visiting the breakout rooms to ensure good interviewing behaviors and an understanding of the CAPI instrument. Additionally, trainees used the breakout room approach to practice refusal conversion in Spanish. Three new interviewers successfully completed 2022 bilingual training and four new interviewers completed the bilingual attrition training.

Post-Remote Training Activities. The post-classroom home study was administered in two parts for the main training and combined into one part for the attrition training (to allow trainees to complete the home study prior to launch of the fall rounds). The first component was distributed on the last day of remote training, and new interviewers had to have successfully completed it before beginning fieldwork. It contained an interactive exercise in BFOS Secure Messaging (BSM) and completion of a mini-mock with a proxy respondent.

The home study also included a memo from the field director reviewing trainees’ tasks in preparation to interview, and it 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. At the same time, all field supervisors received a memo from the field director outlining their role in the post-classroom training through the setting of clear expectations, support, and ongoing training to their interviewers.

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 to their supervisor the best contact strategy for each. Field managers and field supervisors coordinated and implemented a mentoring/buddy plan that paired new hires with experienced field interviewers.

The new interviewers received the second component of the post-classroom home study about 6 weeks after the remote training. This component included both hard-copy materials as well as modules in the electronic LMS. This last component provided interviewers with additional training on respondent cooperation and participation in record-keeping activities. It also provided training on several important Re-enumeration topics and student RUs, and it reinforced interviewer practices related to collecting quality data.

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3.2.1 Experienced Interviewer Training

Spring 2022 Round 1/3/5/7/9 Home Study. The Round 1/3/5/7/9 home study in December 2021 followed established formats but was further expanded to accommodate the introduction of the prescribed medicine look-up, new procedures and applications for AF collection (including e-signature and DocuSign), updated COVID-19 procedures, and changes to the IAS and mFOS and the extended panels. The 6-hour self-paced program contained an instructional memo, electronic AF video demonstration, independent CAPI practice, iPhone training, and a quiz.

CAVI Virtual Training. In spring 2022, all MEPS interviewers were trained in groups over 14 sessions between January and May. New interviewers hired in January 2022 and May 2022 were trained following the new hire training, and the rest of the field staff completed CAVI training starting in February until April. Approximately 314 interviewers completed the training; however, due to attrition, a final count of 299 interviewers, 25 field supervisors and 4 field managers were trained on CAVI. Each session consisted of a 3-day hybrid training, with synchronous sessions and asynchronous self-paced modules. The total training time commitment was 8-10 hours, which included all asynchronous assignments and the post-training mock interview they were required to complete before they could start offering CAVI as a mode to respondents.

Training topics included:

• Setting up the equipment, MEPS iPhone on the phone stand and the MEPS laptop;
  
  
• Creating a meeting in ZoomGov;
  
  
• Setting up the project approved email templates;
  
  
• Launching the interview and letting respondents in from the waiting room;
  
  
• Sharing their screen on ZoomGov to share the online show cards with the respondents;
  
  
• Troubleshooting technical problems; and
  
  
• Knowing when to offer CAVI to respondents.

To support ongoing training, all training videos were posted to the LMS to allow interviewers to rewatch as necessary.

In-Person Refresher Training. Due to the COVID-19 pandemic, the refresher training scheduled for April 2022 was canceled.

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3.2.2 Continuing Education for All Interviewers

Fall 2022 Round 2/4/6/8 Home Study. The Round 2/4/6/8 home study in July 2022 followed established formats. The 2-hour self-paced program contained an instructional memo, example materials, and a quiz. Topics included the extension of the rounds in response to the COVID-19 pandemic, the return to in-person interviewing in select areas, additional training on CAVI interviewing, and additional training on AF collection. New interviewers hired in the spring were required to complete a mock interview with their supervisor, field manager, or designated senior interviewer before beginning the fall rounds of data collection.

Weekly Newsletter. In 2022, 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 topics, 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 eight rounds of MEPS-HC interviewing conducted in 2022. 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 systems include the BFOS, which facilitates case management through case assignment, case status and hours reporting, data quality reporting, and interviewer efficiency. Related systems include the CARI system and the Efficiency Analysis through Geospatial Location Evaluation (EAGLE) GPS validation module. The CARI system allows for review of 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 and attempts to verify the interviewer was at the residence for the duration of the interview to help validate the interview took place. These tools, along with the implementation of models designed to identify cases with a higher propensity for completion, as well as on-hold procedures designed to prevent the overwork of cases in the field, form a comprehensive framework for the management of MEPS data collection.

The field continues to monitor COVID-19 levels and use high-filtration masks as well as other mitigation procedures in areas of high transmission.

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 notified so that he/she could take the proper course of action.

The advance contact calls to Panel 27 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 2022, MEPS interviews were conducted in three modes: in-person, CAVI , and telephone. 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, can share images of records, and can share show card images to allow respondents to select a response. CAVI interviewing started in late spring 2022 but became pervasive in the fall, accounting for over 20 percent of completed interviews. 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 the respondent’s home.

In 2022, electronic AF collection was implemented. The two new electronic methods for completing MEPS AFs (eSignature and DocuSign) are further described in Chapter 2. 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 self-administered questionnaires (SAQs) were mailed by the interviewer shortly after the interview was completed. Pick-up 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, field directors, and the task leader for field operations 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. Field staff referred to this collaborative effort as the “No Region Left Behind” approach.

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 maintained for the spring round of 2022. Data collection began with Rounds 5, 7, and 9, followed by Round 3, and then Round 1. For the Round 1 respondents, the later starting date allowed several additional weeks of elapsed time in which respondents could experience healthcare events to report in their Round 1 interview, with these additional events giving them a more realistic understanding of what to expect in the subsequent rounds of the study.

The field period dates for the eight rounds conducted in 2022 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 more completely report their healthcare events. CARI review was further integrated into weekly monitoring activities with supervisors 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.

Case Potential Listing. The project continued the use of a model predicting a completed interview from a given case (“propensity to complete”) relative to other pending cases in a region. The model is designed to identify cases with a high likelihood of completion at that point in the field period relative to other pending cases. The model is dynamic and is updated weekly based on the specific conditions for pending cases at that time. The model was tested in 2019 to determine if updates were necessary to better fit the data; however, the existing model remains well-suited to current interview conditions and remains in effect even for telephone interviews.

Information from this model is integrated into BFOS (the system used for case management), providing propensity to complete as part of a comprehensive view of a case for a given week. Supervisors were to instruct interviewers—in the absence of other field information that would dictate otherwise—to attempt these cases during the next production week. Table 4-2 illustrates the potential categories used to classify cases on a weekly basis to promote field efficiency.

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4.2 Data Collection Results: Interviewing

Table 4-3 provides an overview of the data collection results for Panels 21 through 27, showing sample sizes, average interviewer hours per completed interview, and response rates. Table 4-4 shows the final response rates a second time, reformatted to facilitate 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 2022, the response rates showed at least a slight increase from 2021 but still lower than prior to 2020. While response rates have not returned to pre-pandemic levels despite a return to in-person interviews, they have begun to rebound. Hours per complete are now higher than pre-pandemic for Round 1, exceeding 13 hours.

*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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Table 4-5 illustrates the mode of data collection for each of the 2022 data collection rounds. CAVI interviews were offered as the first alternative to in-person, and for Round 8 as the primary mode. In all cases, telephone was the least-preferred mode due to concerns regarding data quality and respondent engagement in the study.

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Components of Response and Nonresponse

Table 4-6 summarizes components of nonresponse associated with the Round 1 households by panel beginning in 2017. 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 4-7 through 4-14 summarize results for additional aspects of the 2022 data collection. Because Round 1 is the most difficult of all the rounds, the presentation focuses primarily on Panel?27, Round 1.

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

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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. Given the NHIS redesign implemented in 2018, the partial completes included in the 2022 MEPS sample included some cases that completed only the roster module of the NHIS. The MEPS experience has been that for many of these 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 2022 sample, AHRQ repeated the step taken 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 4-7 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 the previous years shown on the table. Since then, the proportion of partial completes has increased. 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 2020, that difference jumped up to 16.7 percentage points, and there is a 19-point difference in 2021. In 2022, the difference is more in line with years prior to 2020, at 14.7 percentage points.

Sample Domain

Table 4-8 breaks out response information for the NHIS completes and partial completes by sample domain categories for Panel 27. Table 4-8, unlike Table?4-7, 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. The difference across the full 2022 sample was 14.1 percentage points, with NHIS partial completes responding at a lower rate in all domains. Within the individual domains the difference between the response rate for the NHIS completes and the NHIS partials was greatest for the White/other domain?18.1 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 4-9 (shown on the next page) further breaks out response information for Panel 27 by interview mode.

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Refusals and Refusal Conversion

Table 4-10 summarizes the results of refusal conversion efforts by panel. The rate of “ever refused” for RUs in Panel 27 was down to 37.7 percent from its highest level in Panel 26.

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Tracing and Locating

Table 4-11 shows results of locating efforts for households that required tracking during the Round 1 field period by panel. The percent of households that required some tracing in 2022 (11%) dropped 0.3 percent from 2021 and saw its lowest rate in many years; the final rate of households that were not located after tracing efforts also dropped to 3.3 percent from its highest point in 2021.

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Interview Length

Table 4-12 shows the mean length (in minutes) for interviews conducted without interruption in a single session in Panels 21 through 27. Starting in 2020, with the pandemic shutdown, everything moved to telephone interviews; in 2021, a large number of interviews were still conducted by telephone, which took longer as interviewers had to read the show cards aloud, thus adding time to the interview. In 2022, interview time was down. 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 4-13 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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Mean Contact Attempts Per Case

Table 4-14 shows mean contact attempts, by mode and NHIS completion status, for all cases in Round 1 of Panels 25 through 27. The number of contacts required per case in Panel 27 dropped significantly compared to 2020 and 2021.

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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 (MPC) of MEPS. AFs are requested for each unique person-provider pairing identified during the interviews as a source of care to 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.

Prior to 2022 all AFs were paper documents signed by pen. Starting in 2022, two electronic signature options were introduced. Respondents who are available at the time of the in-person interview may sign their forms electronically on the 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 still 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 4-15 shows round-by-round signing rates for the medical provider AFs for Panels 20 through 27. Starting with the rounds fielded in 2022, the rates are shown for each signature method and combined across all methods. Across all rounds in 2022, the eSignature rate is above 90 percent. As a result, the overall signing rate is more in line with 2019 rates, before the pandemic.

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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. The rates calculated for Rounds 2 through 9 include forms fielded but not signed in an earlier round (nonresponse). Included as well were forms that were fielded in an earlier round and signed but rendered obsolete because the person had another health event with the provider after the date on which the original form was signed.

Table 4-16 shows signing rates for pharmacy AFs for Panels 20 through 27. Pharmacy AFs are requested in Rounds 2 through 9, with follow-up for nonresponse in subsequent rounds similar to that for medical provider AFs. As with the medical provider authorizations forms, the overall signing rate in 2022 is in line with the 2019 pre-pandemic rates.

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

Self-administered questionnaires (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 fall 2022, SAQs were requested from Panel 24 Round 8 respondents as well. Table 4-17 shows the SAQ response rates, including both the round-specific rates and the combined rates after the follow-up round was completed.

Response rates have been declining over time, however. Notably, 2020 saw a significant decrease in response rate as a result of telephone interviewing due to COVID-19. The completion rate for initial requests in 2022 remained low. Overall procedures for the distribution and collection of hard-copy materials have not changed with the exception of additional concentrated follow-up. In an effort to stem the tide and introduce additional electronic aspects to the MEPS collection, multimode (web and paper) SAQs will be implemented in 2023.

In Rounds 3 and 5, key adult household members who have been diagnosed with diabetes were asked to complete a short SAQ, the Diabetes Care Supplement (DCS). Forms not completed for pickup at the time of the interviewer’s visit were followed up upon 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 19 through 26 are shown in Table 4-18. Completion rates for the DCS showed a modest but relatively steady decline over time. 2022 experienced a noticeable drop in requests, though the response rate remained about the same.

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4.5 Quality Control

Interviewer performance was monitored through validation case review using GPS, CARI, and telephone interviews. 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. Then, if the case could not be properly validated due to missing data or the GPS information could not be verified to show the interviewer at 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 2022, about 97 percent of completed cases were validated. In the spring rounds, the rate of cases validated by CARI was higher at 65.9 percent compared to 51.4 percent in the fall rounds. The rate of cases validated with GPS data, however, was higher in the fall rounds at 37.8 percent compared to 22.7 percent in the spring. This is likely attributed to the increase in in-person interviews in the second half of 2022, which made GPS data available for more cases. Only 7.8 percent of completed cases were validated by phone in both the spring and fall rounds, and a very small share were validated by mail—less than 0.4 percent in both the spring and fall. While 97 percent of all completed cases were validated in 2022, the percent of each interviewer’s completed cases that were validated averaged 82 percent in the spring rounds and 93 percent in the fall rounds. The increase in the fall rounds was again likely due to the increase in cases that were validated using GPS data.

In addition to validating cases, MEPS field supervisors and managers typically 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 laptops or hard-copy materials with respondents? personally identifiable information (PII), field staff continued to use an automated loss reporting system (a system known as ILRS) to report incidents. Incidents were investigated, updates were sent to AHRQ and MEPS staff who received the initial automated ILRS notification, and results were recorded in an annual MEPS PII log. A security incident report was submitted to the Westat IRB for each confirmed incident.

A total of eight incidents of lost or stolen laptops/iPhones or hard-copy PII were reported in 2022. Of those reported incidents, five involved MEPS laptops and/or iPhones that were reported stolen or lost. In one case, the airline that the interviewer had flown on for MEPS travel found and returned the iPhone to Westat in working order. In the other four cases, two iPhones and two laptops were not recovered even though police reports were filed. The password-protected laptops were shut down at the time of the loss. Since MEPS laptops are fully disc-encrypted, respondent identity was not at risk. The MEPS iPhones are also password-protected.

Two of the reported incidents involved suspected or confirmed loss of hard-copy materials with respondent PII loss or breach of confidentiality. In one instance the interviewer’s car was broken into and the laptop (accounted for above), one hard-copy PSAQ, a notebook page with contact information for another household, and three debit cards (without value) were stolen and not recovered. In the other instance of hard-copy loss, the FedEx package was never delivered. FedEx initiated a search but the package was never found. The respondent in each of these cases was contacted and then sent a replacement package.

A new category of potential PII disclosure emerged in 2022 related to the introduction of the DocuSign signing method for AFs. First, a programming error allowed MEPS participants with the same name to be sent DocuSign AFs that corresponded to people with the same name but from other households. When this situation was reported early in the spring field period, the DocuSign envelope production process was stopped, the program code was revised, and testing was performed before the system was restarted. This impacted five households. All were contacted about what happened and all agreed to continue. The second DocuSign related issue happened because of user error, namely a mis-keying of a household member’s phone number. The result was that AFs were sent to the wrong household. This impacted two households. The respondent from one of the households called the MEPS Respondent Hotline to report the error. In all cases of error, access to forms was suspended upon discovery and forms were reissued to the appropriate household.

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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

Hard-copy materials were assembled prior to data collection for cases fielded in Rounds 3, 5, 7, and 9 during the spring 2022 data collection. These materials consisted of AFs and SAQs outstanding from the previous round. Clerical staff created an RU folder for each case being fielded and inserted any AFs and SAQs that were printed for the case. Since there are no hard-copy case materials generated for Round 1 cases, RU folders were not created prior to data collection for Round 1 cases. With the introduction of electronic AFs during the spring 2022 data collection, the decision was made to no longer pre-print outstanding AFs beginning in the fall 2022 rounds. Additionally, SAQs are mailed to households prior to fall data collection. Therefore, no hard-copy materials were generated, and RU folders were not created for cases fielded for the fall 2022 data collection.

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 BFOS field management system. In the spring rounds, home office staff also shipped the RU folders directly to the interviewers based on the assignments in the logs for the first wave of cases. For later waves, the RU folders were shipped to regional clerks to distribute to the field interviewers.

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. Addresses were first standardized and sent through the National Change of Address (NCOA) database to obtain the most current addresses for mailing. Any mail returned as undeliverable was recorded and the appropriate supervisor was notified. Requests to remail the Round 1 advance package to households who reported not receiving it were prepared and mailed by home office staff.

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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 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 percent of RUs that made calls to the respondent hotline in the spring and fall rounds of 2018-2022. There was a significantly higher percentage of calls to the hotline in both spring and fall 2020. In spring 2021, the percentage of calls to the hotline was more in line with years prior to 2020, but it went back up in spring 2022. The percentage of calls in fall 2022 remained consistent with fall 2021, which was down compared to fall 2020 but still higher than in previous years.

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Table 5-2 shows the number and types of calls received on the respondent hotline during 2021 and 2022. As in prior years, a substantial portion of the Round 1 calls were for refusals. In spring 2022 there was a higher percentage of calls for appointments in all rounds compared to the previous year. However, in the fall rounds the percentage of calls for appointments decreased significantly from the previous year.

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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.

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 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 BFOS 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 reviewed by receipt staff, then scanned and uploaded to the secure server. 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/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 2022. 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 CAPI Helpdesk coordinated tracking and shipping of all field laptops, field laptop assignment, 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 2020 delivered in 2022.

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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 2022, 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 is 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 2022, 12.1 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 34.3 percent. For fall 2022, 12.7 percent of cases received from the field included a comment while cases with any issue totaled 25.0 percent.

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Field interviewers must select one 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 s 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

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 selected by the interviewer, so the specification requires an additional Dex variable for each possible value. Code All That Apply is another transformation class. All of the classes are developed through discussions with AHRQ and are sent to AHRQ for approval.

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. The Dex tables are generally identical to the legacy Cheshire segments, such as BASE, HOME, or PERS. This set of intermediate data files is known as pre-Dex and has the same structure as the Dex database, but all files are in the Blaise format. 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 (COTS) software system for intelligent data capture and image processing, was used in 2022 to capture data collected in the DCS and the SAQ. 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.

As SAQs evolve to be multimode (web and paper) in 2023, we will update this section to discuss data harmonization and web data collection.

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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/Occupation; and
  
  
• Geographic identifiers.

Condition and Prescribed Medicine Coding

In 2022, coding was performed on the conditions and prescribed medicine text strings reported by household respondents for calendar year 2021. An automated system enabled coders to easily search for and assign the appropriate 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 are tracked in the system and error rates calculated weekly. Both the condition and prescribed medicine coding efforts were staffed by three coders.

During the 2022 coding cycle, coding managers continued to refine a number of new and revised procedures and processes implemented for the coding of 2018 data in 2019. These revisions were a result of many months of collaboration between AHRQ and Westat in evaluating all aspects of the coding processes for household reported conditions, prescribed medicines, and sources of payment, including updating and maintaining the authority tables and the development of tools and resource documents to facilitate the execution of these tasks. Also in 2019, Westat deployed a new web-based coding system for condition and prescribed medicine coding to replace the Access database previously used. The new system better supports downstream-processing activities and aligns with other web-based systems used across other components of MEPS. All aspects of coding work are supported by a number of scheduled quality control checks before, during, and after each coding cycle.

In 2022, medical conditions 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 CCSR. A total of 2,863 unique strings were manually coded and the authority table was constructed with AHRQ-approved code assignments. This represented a 71-percent reduction in the average number of strings needing manual review before the implementation of the condition pick list and search tool was integrated into the CAPI instrument. The overall error rate for coders was 1 percent, below the contractual error rate goal of 2 percent.

Prescription medicine text strings for data year 2022 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 40 percent each year. The matching programs are reviewed and approved each year. A total of 7,135 strings were manually coded from 2022 data. In a process similar to condition text strings, the prescription medicine text strings undergo two rounds of unduplication 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 will impact the number of strings that need manually coding in 2023. The overall coding error rate (across all coders) was 1 percent, 1 percent 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.

Source of Payment Coding

Source of payment information (SOP) 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 Medical Provider Component (MPC) of MEPS uses the same set of source of payment 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 these to ensure the authority tables from each contractor are aligned.

Each year, the source of payment text strings extracted from the reference year data is 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 source of payment 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 HMOs; 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 2022 was for the payment sources reported for 2021 events. For cases when the bill was paid by a source identified in response to a direct question about payment (REIMNAM), a total of 1,577 previously coded sources of payment text strings were reviewed and updated as needed. After unduplication of the strings reported for 2021, coders reviewed and coded 1,935 strings. If the bill was sent to a source other than the respondent and the respondent names that source (WHOBILL1), coders reviewed and coded 3,658 strings. For text strings reported as direct payers for prescription medicine (SRCNAME), 554 new text strings were reviewed and coded by coders.

Industry and Occupation Coding

Industry and Occupation coding is performed for MEPS by the Census Bureau using the Census Bureau’s Demographic Surveys Division’s (DSD’s) computer-assisted industry and occupation (I&O) codes, which can be cross-walked to the 2007 North American Industrial Classification (NAIC) coding system, and the 2010 Standard Occupational Classifications (SOC). The codes characterize the jobs reported by household respondents and are released annually on the FY JOBS file. During 2022, 12,409 jobs were coded for the 2021 JOBS file.

GEO Coding

The Westat Geographic Information Systems (GIS) division GEO-codes 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 2022 coding cycle, 22,857 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 non-institutional population’s access to, use of, and payments for healthcare.

The Oracle system has a separate database for each data year. This is a recent departure from having individual databases for each panel/year combination. The goal of this is to make data processing more streamlined, and this was necessitated by extending Panels 23 and 24 to collect data through nine rounds.

Due to the pandemic, Panels 23 and 24 are being extended through Round 9. The MEPS 2021 database contains Panels 23 through 26, and the MEPS 2022 database contains Panels 24, 26, and 27.

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:

1. Programmatic updates can correct problems affecting a large volume of cases that fail a basic edit.
   
   
2. 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 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. 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 reviews 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:

1. Review approved high- and detailed-level specifications.
   
   
2. Write programs for each specification using SAS or SQL.
   
   
3. Test all programmed code for accuracy.
   
   
4. Conduct detailed code reviews to review specifications and code.
   
   
5. Test code on SAS production files or Oracle database without committing.
   
   
6. 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.
   
   
7. 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

Public Use File Deliveries

The principal files delivered during calendar year 2022 are listed below:

• Full-Year 2020 Population Characteristics File;
  
  
• Full-Year 2020 Use and Expenditure File;
  
  
• Full-Year 2020 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 2020 Expenditure Event files for events not included in the MPC data collection, including dental events, office-based non-physician events, and other medical expenses;
  
  
• Full-Year 2020 Prescribed Medicines Expenditure File;
  
  
• Full-Year 2020 Medical Conditions File;
  
  
• Full-Year 2020 Jobs File;
  
  
• Full-Year 2020 Appendix to MEPS Event Files; and
  
  
• 2020 Person Round Plan File.

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 2022 appears in the appendix.

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 2022 for MPC collection of data about 2021 health events, Westat again applied the program developed in 2014 for de-duplicating 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.

Early in 2022, following completion of MPC data collection and processing for 2020 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 2020 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.

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Appendix A
Comprehensive Tables – Household Survey

* RU-level sample size for this table derived from field management system counts and operational reports detailing 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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Note: Figures shown are based on original NHIS sample and exclude reporting units added to the sample as “splits” and “students.”

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