MEPS Annual Methodology Report 2023

Deliverable Number: 121bE.102
Contract Number:75Q80120D00024
July 1, 2024

Authors
Westat
Westat Reference Number: 2-7-736
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 the Computer-Assisted Personal Interviewing (CAPI) Instrument for 2023
2.3 Testing of the Questionnaire and Interviewer Management System
2.4 Changes to Materials and Procedures for 2023
3. Recruiting and Training
3.1 Field Interviewer Recruiting for 2023
3.2 2023 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. Comprehensive Tables – Household Survey
1-1 Initial MEPS sample size (RUs) and number of National Health Interview Survey PSUs, all Panels
Data collection periods and starting reporting unit (RU)-level sample sizes, spring 2019 through fall 2023
1-3 Percentage of National Health Interview Survey (NHIS) households with partially completed interviews in Panels 4 to 28
1-4 Distribution of Panel 28 sampled reporting units (RUs) by sample domain
2-1 Supplements to the computer-assisted personal interviewing (CAPI) core questionnaire (including hard-copy materials) for 2023
3-1 Staffing for spring field period, 2019–2023
3-2 Spring attrition rate among new and experienced interviewers, 2019–2023
3-3 Fall attrition rate among new and experienced interviewers, 2019–2023
3-4 Annual attrition rate among new and experienced interviewers, 2019–2023
4-1 Data collection schedule and number of weeks per Round of data collection, 2023
4-2 Case potential categories for classifying and prioritizing casework, spring 2023
4-3 MEPS-HC data collection results, Panels 22 through 28*
4-4 Response rates by data collection year, 2014–2023
4-5 Completed cases by mode of interviewing for Panels 24 through 28
4-6 Summary of MEPS Round 1 response and nonresponse, 2018–2023 Panels
4-7 Summary of MEPS Round 1 response, 2018–2023 Panels, by National Health Interview Survey (NHIS) completion status
4-8 Summary of MEPS Panel 28, Round 1 response rates, by sample domain by National Health Interview Survey (NHIS) completion status
4-9 Summary of MEPS Panel 28, Round 1 response rates, per interview mode, by sample domain by National Health Interview Survey (NHIS) completion status
4-10 Summary of MEPS Round 1 results for reporting units who ever refused, Panels 22 through 28
4-11 Summary of MEPS Round 1 results for reporting units who were ever traced, Panels 22 through 28
4-12 Interview timing comparison, Panels 22 through 28 (mean minutes per interview, single-session interviews)
4-13 Interview timing comparison by interview mode for Panels 24 through 28 (mean minutes per interview, single-session interviews)
4-14 Mean contact attempts by National Health Interview Survey (NHIS) completion status and interview mode, Round 1 of Panels 26 through 28
4-15 Signing rates for medical provider authorization forms for Panels 21 through 28
4-16 Signing rates for pharmacy authorization forms for Panels 21 through 28
4-17 Results of self-administered questionnaire (SAQ) collection for Panels 21 through 28
4-18 Results of Diabetes Care Supplement (DCS) collection for Panels 20 through 27
5-1 Number and percentage of respondents who called the respondent information line, 20192023
5-2 Calls to the respondent information line, 2022 and 2023
6-1 2023 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, Panels 15-28
A-7 Summary of MEPS Round 1 results for RUs who were ever traced, Panels 15-28
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 Interview length by mode for Panels 24-28
A-12 Signing rates for pharmacy authorization forms
A-13 Results of self-administered questionnaire (SAQ) collection
A-14 Results of Diabetes Care Supplement (DCS) collection*
A-15 Results of patient profile collection
A-16 Calls to respondent information line
A-17 Files delivered during 2023
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 noninstitutionalized population. The project has been in operation since 1996, each year producing a series of annual estimates of health insurance coverage, healthcare utilization, and healthcare expenditures. This report documents the principal design, training, data collection, and data processing activities of the MEPS-HC for survey year 2023.

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 2.5-year period.

This report describes work performed for all of the Panels active during calendar year 2023. Data collection operations in 2023 were for Panel 24, Round 9; Panel 26, Round 5; Panel 27, Rounds 3 and 4; and Panel 28, Rounds 1 and 2. Data processing activity focused on delivery of full-year utilization and expenditure files for calendar year 2021.

The report touches lightly on procedures and operations that remained unchanged from prior years, focusing primarily on the results of the 2023 operations and features of the project that were new, changed, or enhanced for 2023. Tables in the body of the text highlight the 2023 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 2023 sample and activities associated with preparing the sample for fielding. Chapters 2 through 5 discuss activities associated with the data collection for 2023: updates to the survey questionnaire and field procedures; field staff recruiting and training; data collection operations and results; and home office support of field activities. Chapter 6 describes data processing and data delivery activities.

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1. Sample

Each year, a new, nationally representative sample for the Medical Expenditure Panel Survey Household Component (MEPS-HC) is drawn from among households responding to the previous year’s National Health Interview Survey (NHIS). Households in a new Panel typically participate in a series of five interviews that collect data covering two full calendar years. For each calendar year, the sample respondents from two Panels—one completing its first year in the study (Round 3) and one completing its second year (Round 5)—are combined for analysis purposes, resulting in a series of annual estimation files. 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 2023, Panel 28, 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 22-27). Specifically, the MEPS household sample was randomly selected from among those that participated in the NHIS during the first three quarters of 2022 and who had been assigned to NHIS Panels 1 and 3, the NHIS Panels designated for MEPS.

This chapter describes the 2023 MEPS sample drawn from 2022 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 28 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 28 is based on the number of PSUs associated with MEPS after the 2016 NHIS sample redesign, the seventh such MEPS Panel under this design. The reduction in the number of PSUs after Panel 22 stemmed from further modifications to the NHIS design. The MEPS sample units presented are RUs, each of which represents a set of related persons living together within the same NHIS-responding household selected for MEPS participation. Related members of the NHIS households sampled for MEPS who move as a unit during the MEPS data collection period (as well as separate individuals) form new RUs for interviewing purposes. Each new RU is followed over the course of the five MEPS data collection Rounds and interviewed at their new address.

* RUs: reporting units; PSUs: primary sampling units

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

However, with the extension of Panels 23 and 24 beginning in 2020, additional Rounds were fielded: In 2023, we fielded Round 9 for Panel 24, the last of the extension Panel Rounds. Table 1-2 summarizes the combined workload for the January-June and July-December periods from spring 2019 through fall 2023.

Over the years shown in Table 1-2, the combined spring and fall workload has ranged from a low of 28,566 in 2023 to a high of 40,168 in 2021. Typically, the interviewing workload during the spring field period, when three Panels are active, is substantially larger than during the fall, when there are only two. In 2023, there were four active Panels in the spring field period and two in the fall field periods. The spring field period still had more cases, with 18,155 cases fielded, while the fall workload had 10,411 RUs, the lowest of the 5 years shown.

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

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 28 sample distribution by domain.

* 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 28.

**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 2023 MEPS sample was received from AHRQ and the National Center for Health Statistics (NCHS) in two deliveries. The first delivery, containing households sampled from the first and second quarter of the 2022 NHIS, was received on September 14, 2022. Households selected from the third quarter of the NHIS were delivered on December 2, 2022.

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 2023 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 numerous 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 2023 are detailed in this chapter.

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2.2 Changes to the Computer-Assisted Personal Interviewing (CAPI) Instrument for 2023

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.

Section-specific changes for the 2023 data collection period, both spring and fall, are summarized below.

Start/Restart (ST). While the MEPS informed consent process was previously handled outside of CAPI, recent changes in materials and procedures meant it was best to incorporate this at the beginning of the instrument to ensure it was consistently administered. A new item was added in the ST section to ensure that interviewers present the informed consent information to any new respondent. This item has an accompanying show card that matches the informed consent handout.

Reenumeration (RE). The interviewer instruction “IF NOT OBVIOUS, ASK:” was removed from all items collecting sex in the Reenumeration and Off-Path sections. The removal of the interviewer instruction promotes inclusivity and ensures consistent administration.

Provider Lookup. Two notable changes were made to the provider lookup based on analysis conducted as part of the recent National Provider Identifier (NPI) contract line item number (CLIN). First, the set of potential providers preloaded into the lookup for a specific household is now smaller and tailored based on urbanicity. Previously, all providers within 100 miles of a household were included. Now, the maximum distance varies based on urbanicity, according to rural-urban commuting area (RUCA) code defined by the U.S. Department of Agriculture. For example, if the household is in a large city or metropolitan area, the lookup includes providers within 55 miles. For an RU in a rural area, the lookup includes providers within 90 miles. Reducing the maximum distance means that fewer unlikely providers will be displayed in the lookup search results. This should make the search process more efficient.

Second, a new facility checkbox feature was added to the provider lookup. If this box is checked, only facility-providers display in the search results. If this box is unchecked, both facility-providers and person-providers display in the search results (as was the prior convention). When the provider lookup is launched for HS (Hospital Stay), ER (Emergency Room), and OP (Outpatient) events, the facility box will be checked by default because the provider for these event types should be a facility. The ability to filter out person-providers should help interviewers find a matching hospital or facility entry more quickly and easily. It should also reduce the selection of the wrong provider type for certain event types, which triggers a hard check and requires searching the lookup again.

Pharmacy Lookup. The pharmacy lookup was updated to include mail-order and specialty pharmacies across every lookup, regardless of the household’s ZIP Code. The lookup was also expanded to include mail-order pharmacies associated with the U.S. Department of Veterans Affairs (VA) or TRICARE, such as Express Scripts, VA Mail Order Pharmacy, and Meds by Mail. The inclusion of these mail-order pharmacies negates the need for the interviewer to manually enter these pharmacies. This may improve the Medical Provider Component (MPC) match rate for these newly added pharmacies. Finally, the pharmacy lookup was modified in the same way as the provider lookup (described above) with regards to a tailored approach based on a household’s urbanicity.

Condition Lookup. A few minor changes were made to the condition lookup. For those entries directly selected from the condition pick list, the List ID is now saved along with the text of the selected entry for analytic purposes. Additionally, the hard check that is used to prevent adding duplicates of the same conditions to the roster was modified to only check the first 30 characters of the text string since that is the maximum length for existing condition entries. The condition lookup was also updated with a small number of additional entries.

Prescribed Medicine Lookup. Two minor behind-the-scenes changes were made to the prescribed medicine lookup for analytic purposes. As with the condition lookup, for those entries directly selected from the pick list, the List ID is now saved along with the text of the selected entry. Additionally, when entries are “edited” within the prescribed medicine lookup, a flag is now saved to indicate this. The edit functionality is only available from the prescribed medicine lookup, not any of the other MEPS CAPI lookups. The prescribed medicine lookup was also updated with several additional entries.

Provider Probes (PP). The extended family path was eliminated in the Provider Probes. Now, the initial family path also asks about extended family members by use of fills. These fills use variable question text to ask about each other RU member. Additionally, there was a change to an item that asked if extended-family RU members without events reported let the respondent know about their healthcare. This item was revised so that it is also asked of family RU members besides the respondent (for those with no events reported).

A minor revision was also made when there are multiple RU members with different reference period end dates. The PP question wording was previously using the earliest end date for any RU member, but it now uses the latest end date for any RU member. Displaying the latest end date ensures that the respondent is considering the broadest reference period possible and does not inadvertently miss reporting any events.

Other Medical Expenses (OM). In cross-round interviews where an RU member has Other Medical Expenses, two follow-up questions are asked to determine if the expenses occurred in Year 1 of the cross-round (OM60) or Year 2 of the cross-round (OM70). A soft check was added to OM70 to prevent the illogical recording of “No” to both items.

Charge/Payment (CP). The item collecting amount paid out of pocket (CP200) was reworded in response to audiorecordings of the interactions between interviewers and respondents. The item previously asked, how much of the total charge did anyone in the family pay “out of pocket,” that is, before any reimbursements? The phrase “that is, before any reimbursements” was omitted from the question text to help increase understanding for respondents.

COVID-19 (CV) and Related Items. The CV section (which was added to the CAPI instrument in 2021) was removed for 2023. The two remaining items from this section regarding COVID-19 vaccinations were moved to the Additional Healthcare (AH) section. In addition, a new series of COVID-19-related items were added to the Priority Condition Enumeration (PE) section. These items ask if RU members ever had COVID-19 or long COVID symptoms, about the impacts of these symptoms, and when their most recent COVID-19 infection was.

Employment (EM) and Related Sections. A minor change was made to modify the routing to the question which asks why an RU member is not working during the interview reference period (EM750) so that more people are asked this question. The question is now asked for everyone who currently reports not working, and is also re-asked in Rounds 3 and 5 for those that continue to be unemployed (except for those that are retired).

Health Insurance (HX) and Related Sections. There were numerous changes to the Health Insurance sections for spring 2023. First, all questions related to premiums in Medicaid and some premium-related questions for Government Hospital-Physician (GHP) insurance in the HX and Old Public Related Insurance (PR) sections were removed, since these items were found to be not common for Medicaid and GHP programs. Moreover, Medicare Part B questions (specifically HX340 and HX350) were removed since these items are not being used much for policy-relevant research. Removing these aforementioned items also helps reduce respondent and interviewer burden.

Another update for spring 2023 was reducing the number of response options used for some HX questions and their corresponding show cards. Specifically:

• Show card HX-2 (used at HX190, HX200, and HX300) was reduced from 11 to 5 response options of direct purchase coverage.
  
  
• Show card HX-6 (used at HX620 and OE130) was reduced from 11 to 5 response options of health insurance coverage types.
  
  
• Show card HX-7 (used at HP40 to identify the insurance type for self-employed, firm-size-1 coverage) was reduced from 8 to 5 response options.

Additionally, the response options on these show cards were reordered so more prevalent options are listed first, which is expected to decrease burden.

Next, the introductory text at HX190 was removed to make the question more pointed and ensure key language is emphasized. Each year, hundreds of respondents report coverage at HX190 that appears to duplicate coverage already reported in the Employment section. By removing the introductory text, the existing phrase “not counting insurance you already told me about” should be more noticeable to respondents, which will ideally reduce duplicate insurance coverage reporting. The question text at HX190 was also modified to explicitly include dental and vison to encourage responses that include these types of coverage.

Finally, new follow-up items were added to expand collection of dental coverage and ensure that stand-alone dental policies are not erroneously missed. This includes HX415 and PR35 to collect information about dental coverage related to Medicare Advantage plans, as well as HX625 and OE135 to collect information about dental coverage for private insurance plans.

Contacting Module (CM). The CM60 grid collects an email address and cellphone number for each adult household member. This information can be used by MEPS to send emails and texts to RU members regarding follow-up tasks like DocuSign authorization forms or self-administered questionnaires (SAQs). To ensure that email addresses and cellphone numbers are correctly formatted and valid for contacting (e.g., name@example.com), hard checks and soft checks were added to this grid in spring 2023. Analogous hard and soft checks were also added to CM47 and CM55_01, which is where the email address and cellphone number for proxy respondents are collected.

In fall 2023, minor changes were made to the wording of CM60 grid items to tailor the language to better match various situations that are encountered in the field. When updating an email address or cellphone number from what was provided in a prior Round, the question text was simplified. In contrast, when requesting email address or cellphone number information for someone that has not previously provided that information to MEPS, we added a short optional statement that interviewers can use to explain why MEPS collects contact information and how it will be used.

Respondent Forms (RF). In response from feedback from interviewers, an interviewer-only screen that summarized requested authorization forms for the household was removed. As the vast majority of authorization forms are no longer completed by paper, interviewers found this screen unnecessary for preparing authorization forms. Another improvement was carrying over any “other names” (e.g., maiden name or other legal name) under which RU members may have records filed for use on authorization forms. The option is always available to update the carried over “other name” if needed.

Quality Supplement (QS). Supplemental SAQs are introduced and collected in the QS section of the CAPI instrument. For fall 2023, multiple changes were made to the QS section to accommodate the new multimode SAQ approach that allowed both web and paper response.

First, the QS section was moved to later in the CAPI instrument, immediately after RF and before Closing (CL). Since authorization forms collected in the RF section are extremely important to MEPS, we wanted to request those signatures before we introduced the SAQ request. The QS section was also revised so that each RU member that was eligible for the SAQ was assigned to the web or paper mode. The assigned mode was based on availability of email and/or cellphone information for each eligible RU member as collected in the CM section.

No significant change in follow-up procedures from prior years was made for RU members assigned to the paper mode. When RU members are assigned to the web mode, the interviewer introduces the web SAQ and provides a physical reminder card with further information. However, all web SAQ invitations and reminders were sent post-interview. For more details about the multimode SAQ procedures, see the next section.

Supplements to the CAPI Instrument

Table 2-1 shows the supplements for the Rounds administered in calendar year 2023. As mentioned above, the most notable change was the adoption of a multimode (web/paper) approach for the Your Health and Health Opinions SAQ. However, the content of the SAQ was unchanged from prior years; both the web and paper version of the SAQ were estimated to take about 7 minutes to complete. When RU members were assigned to the web mode for the SAQ, they were sent automated invitations and reminders by text and/or email. The first invitation was sent 2 days after the main interview was completed and transmitted to the home office. The web SAQ was hosted at www.MEPSDocs.org/survey. Every invitation and reminder message about the web SAQ included a link to this URL, as well as a unique personal identification number (PIN) the RU member used to log in to their survey.

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2.3 Testing of the Questionnaire and Interviewer Management System

Testing for the spring 2023 (Rounds 1, 3, 5, and 9) instrument was conducted between September and December 2022. Testing for the fall 2023 (Rounds 2 and 4) instrument was conducted between March and June 2023. Since 2018, many of the testing approaches and procedures used for the technical upgrade have been continued or adapted to maintain a comprehensive testing plan that supports the ongoing instrument development schedule.

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

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

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

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

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

The fall 2023 development cycle also included extensive testing related to multimode SAQs. This included unit and integrated testing of the revised screens and routing in the CAPI instrument and the web version of the SAQ, data entered via web, text and email invitations and reminders, the MEPSDocs website, and receipt procedures, including the use of various devices to access and complete the web surveys.

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2.4 Changes to Materials and Procedures for 2023

The manuals and the materials for the 2023 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).

The separate authorization form manual and Computer-Assisted Video Interviewing (CAVI) Operations Manual that were distributed in 2022 were incorporated into the 2023 field interviewer procedures manual.

The manual was available electronically on the MEPS laptop. Hard copies were distributed to new hires only.

Electronic Case Materials

To help prepare for upcoming interviews, the electronic face sheet in the IMS provides interviewers with information needed to contact their assigned households and familiarize themselves with the composition of the household and relevant details about their prior history with the survey. No changes were made to the face sheet in 2023.

The IMS also contains a Payment module to activate the debit card incentive after an interview is completed, 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 IAS, which supports follow-up for authorization forms and SAQs not completed at the time of the interview. No significant changes were made to the IMS in 2023.

Interviewers continued to be equipped with iPhones for their MEPS work. When changes were made to the laptop IMS, the iPhone mobile field operating system (mFOS) application generally had corresponding changes to match.

To facilitate follow-up efforts for web SAQs, a new SAQ Forms module was added to provide the current status for SAQs.

Respondent Materials

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

The MEPSDocs.org website continued to be available to respondents to boost cooperation, ease legitimacy or COVID-19 concerns, and offer recordkeeping tools. 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. Finally, the MEPSDocs website also hosted the web SAQ during the fall 2023 field period.

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3. Recruiting and Training

3.1 Field Interviewer Recruiting for 2023

Overview. For spring 2023 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 2023 data collection (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 2019-2023.

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

Spring 2022 Supplemental 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.

Spring 2023 Supplemental Staffing – ***Note that the total of 103 new interviewers includes 37 interviewers who were trained mid-April to shore up the spring 2023 data collection staff.

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Recruiting Goals. Based on a projected sample size of approximately 22,000 RUs across the four Panels to be fielded for spring 2023 and the likely number of experienced MEPS interviewers available at the end of fall 2022 data collection (about 265), including a MEPS travel team of 6 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 2023 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 2023 began in early October 2022 and continued through mid-December 2022. Since MEPS was transitioning back to in-person interviewing, MEPS only recruited for in-person interviewers (both English-speaking and bilingual). In anticipation of difficulties in hiring enough new interviewers during the main recruiting period, MEPS planned and implemented an additional Round of recruiting that began in February and continued through mid-March for an in-person supplemental training in April.

Recruiting Outcomes. During the main recruiting period, 84 candidates accepted job offers and 66 were hired. With the addition of these new trainees, the project began 2023 data collection with a total of 331 interviewers.

The goal was to add 50 more interviewers during the supplemental recruiting period.

Interviewer Attrition during 2023 Data Collection. During the spring data collection, a total of 30 new interviewers and 40 experienced interviewers were lost to attrition. An additional 18 new interviewers and 22 experienced interviewers were lost during the fall Round. Total attrition for the year (see Table 3-4) was 29.7 percent, a rate more in line with the attrition level of 30 percent during the first year of the pandemic when the data collection mode switched from in-person to telephone interviewing. In looking forward to 2024, MEPS will again aim to expand the interviewing staff so that we can begin data collection with close to 400 interviewers. The breakdown of 2023 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 2019 through 2023. Note that the total spring 2023 attrition rate of 18.9 percent is equivalent to the 2022 attrition rate. The new hire spring attrition rate remains high but has decreased to the level of new hire attrition experienced in spring 2019, the year before the pandemic hit and the data collection mode changed. In 2023, the main new interviewer training was conducted in person for the first time since 2020.

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Table 3-3 shows the overall attrition rate during the fall data collection period from 2019 through 2023. Note that the total fall 2023 attrition rate was 13.3 percent, comparable to the fall attrition rate in 2022. However, the fall 2023 rate is still higher than the 8.3 percent rate of fall 2019 and 8.0 percent of fall 2020.

Over the past 5 years, the average annual combined attrition rate (new hires and experienced interviewers) has been 29.8 percent. The average annual attrition rate among new hires has been 48.6 percent and 22.6 percent among experienced interviewers.

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3.2 2023 Interviewer Training

The overall structure for training new interviewers in 2023 was a departure from the virtual training approach conducted in 2022 due to the COVID-19 pandemic. The goals of the 2023 training were to address the challenges associated with the recruitment and retention of field data collectors through several approaches including engagement of new hires between the time of hire and in-person training, the reduction of the length and complexity of training, and additional opportunities for interaction between new hires and existing field data collectors.

The 2023 training package reflected a blended training approach that included 5.5 days of in-person training that focused on Rounds 3 and 5 interviewing, preceded by asynchronous and synchronous virtual content; CAVI training as part of in-person training, with post-training follow-up; a post in-person asynchronous training on additional topics; and a 2-day virtual training that focused on Round 1 interviewing. An attrition training with the same components was also conducted in April 2023.

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

In-Person Training: For the 5.5 days of project-specific training, each trainee was assigned to one of six training classrooms (3 for the April attrition training) staffed by a primary trainer and a support trainer and one or two classroom runners. The selection of trainers for the 2023 new hire training was based on several criteria, including experience training with the CAPI instrument, overall project knowledge, and prior training experience. Prior to in-person training, all training and support staff received a training on the content, activities, and procedures, roles, responsibilities, and logistics associated with training.

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

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

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

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

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

Trainees that required remedial practice worked one-on-one with their training team or the floater team, either prior to or after the training day, and were able to provide focused practice based on the needs of the trainee.

Sixty-four new hires successfully completed the main training, and 37 successfully completed the attrition training.

Bilingual trainees in January received an additional half-day of bilingual training immediately following the completion of regular project training. Trainees completed a Round 3 dyad in Spanish. Additionally, trainees practiced advanced cooperation in Spanish. Five new interviewers successfully completed 2023 in-person bilingual training. Bilingual training for new hires during the attrition training was performed virtually. Eleven new interviewers completed the bilingual attrition training virtually.

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

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

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

After the successful completion of in-person training, new interviewers participated in CAVI practice sessions with Westat staff. This follows the model of the 2022 CAVI interviewing training program.

2-Day Round 1 Virtual Training: Westat presented a 2-day training on Round 1 concepts in late February 2023. Trainees participated in one of three virtual classrooms (2 virtual classrooms in the May attrition training.) Both of the training sessions contained a synchronous virtual session and asynchronous sessions delivered by the LMS.

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

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

Fifty-seven new hires completed the main Round 1 training, while 35 new hires completed the attrition Round 1 training.

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3.2.1 Experienced Interviewer Training

Spring 2023 Round 1/3/5/9 Home Study. The Round 1/3/5/9 home study in December 2022 followed established formats. The content of the home study focused on new procedures and applications for the Interview Management System (including the Respondent Payment module and the electronic Household Health Care Summary [eHHCS]) and the BFOS. Topics also included follow-up procedures for self-administered questionnaires, the introduction of informed consent within the CAPI instrument, changes to the Provider Probes section, provider lookup, and new COVID-19-related questions. The 3-hour self-paced program contained an instructional memo and knowledge check.

In-Person Refresher Training. In 2023, AHRQ decided to forgo in-person refresher training.

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3.2.2 Continuing Education for All Interviewers

Fall 2023 Round 2/4 Home Study. The Round 2/4 home study in July 2023 followed established formats. The 2-hour self-paced program contained an instructional memo, interactive self-paced modules on the LMS about multimode SAQ procedures, example materials, and a quiz. Topics included CAVI best practice reminders, updates to the MEPSDoc website, multimode SAQ collection, and CAPI updates. New interviewers hired in the spring (January and April) were required to complete a mock interview with their supervisor, field manager, or designated senior interviewer before beginning the fall Rounds of data collection.

Weekly Newsletter. In 2023, MEPS continued offering its field interviewer newsletter in a weekly format. The newsletter allows for additional training opportunities in a concise format and the ability to deliver content as needed to the field. Topics included CAPI questionnaire information, procedural content, and answers to field interviewer questions.

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4. Data Collection

This chapter describes the MEPS-HC data collection operations and provides selected results for the six Rounds of MEPS-HC interviewing conducted in 2023. 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 computer-assisted recorded interviewing (CARI) system and the Efficiency Analysis through Geospatial Location Evaluation (EAGLE) Global Positioning System (GPS) validation module. The CARI system allows for review of 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.

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

The advance contact calls to Panel 28, 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 2023, MEPS interviews were conducted in three modes: in-person, CAVI, and limited 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 and can share images of records, and interviewers can share show card images to allow respondents to select a response. CAVI interviewing started in late spring 2022 but became pervasive, now accounting for over 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 2023, authorization forms (AFs) were collected in one of three ways: eSignature, DocuSign, or paper (more detail in Section 4.3) The AF procedures varied based on the interview mode and household contact information provided to MEPS. During in-person interviews, available household members signed on the interviewer’s laptop (eSignature). For household members not available during the in-person interview, or for CAVI or telephone interviews, respondents were sent a link via email or text to sign forms in DocuSign. Paper AFs were still used when requested or for household members unavailable and not eligible for DocuSign due to not providing an email address or cellphone number.

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

MEPS field managers, 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 2023. Data collection began with Rounds 5 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 2023 are shown in Table 4-1.

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Data Quality (DQ) Monitoring. The MEPS DQ field monitoring system and procedures allowed supervisors and field managers to identify interviewers whose work deviated from quality standards and who might need additional coaching on methods for getting respondents to report their healthcare events more completely. CARI review was further integrated into weekly monitoring activities, with 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 the 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 28, 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 Round-by-Round comparisons across Panels and years. In addition to the main Panel Rounds, both tables display the extended Panel Round data for Panels 23 and 24.

Of the data collection Rounds conducted in 2023, the response rates showed a moderate increase from 2022 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 continued to rebound. Hours per complete continue to increase higher than pre-pandemic for Round 1, at 13.7 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 2023 data collection Rounds. CAVI interviews were offered as the primary mode for Round 5 and Round 9, while telephone was the secondary mode, followed by in-person where necessary. For all other Rounds, the primary mode was in-person with CAVI as the secondary mode followed by telephone.

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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 2023 data collection. Because Round 1 is the most difficult of all the Rounds, the presentation focuses primarily on Panel 28, Round 1.

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

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

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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 2023 sample, AHRQ repeated the step taken in most years since 2012 of sampling the NHIS partial completes in the “White/other” category at a lower rate than the NHIS completes.

The upper portion of Table 4-7 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 previous years shown on the table. Since then, the proportion of partial completes has increased. The proportion in 2023 is comparable to 2022. 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 2023, the difference is more in line with years prior to 2020, at 15.6 percentage points.

Sample Domain

Table 4-8 breaks out response information for the NHIS completes and partial completes by sample domain categories for Panel 28. 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. NHIS partial completes responded at a lower rate in all domains. Within the individual domains, the difference between the response rate for the NHIS completes and the NHIS partial completes was greatest for the White/other domain—19.3 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 28 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 28 was down to 36.8 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 percentage of households that required some tracing in 2023 (10.2%) dropped 0.8 percent from 2022 and saw its lowest rate in many years; the final rate of households that were not located after tracing efforts also dropped to 2.5 percent from its highest point in 2021.

Interview Length

Table 4-12 shows the mean length (in minutes) for interviews conducted without interruption in a single session in Panels 22 through 28. There were a larger number of telephone interviews in 2020 and 2021 due to the pandemic shutdown. These took longer as interviewers had to read the show cards aloud, thus adding time to the interview. 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. In 2023, overall timings continued to drop, approaching pre-pandemic levels.

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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 26 through 28. While overall contact attempts are comparable to 2022, contact attempts for NHIS completes dropped slightly in 2023, while the number of attempts for NHIS partials increased.

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

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4.3 Data Collection Results: Authorization Form Signing Rates

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

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

Table 4-15 shows Round-by-Round signing rates for the medical provider AFs for Panels 21 through 28. Prior to 2022, all authorization forms were paper. Starting with the Rounds fielded in 2022, the rates are shown for each signature mode and combined across all modes. In 2023 for Rounds 3 and 5, there was a drop in overall signature rate. For Panel 26, Round 5, this is due to a higher proportion of DocuSign AFs as compared to Panel 25, Round 5. For Panel 27, Round 3, there is a decrease in the signature rates for both DocuSign and paper AFs as compared to Panel 26, Round 3. The fall Rounds in 2023 saw an increase in the overall signature rate, with the biggest jump being in the signing rate for DocuSign AFs.

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

Table 4-16 shows signing rates for pharmacy AFs for Panels 21 through 28. Pharmacy AFs are requested starting in Round 2, with follow-up for nonresponse in subsequent Rounds similar to that for medical provider AFs. As with the medical provider authorizations forms, the overall signing rate in the first half of 2023 dropped from the first half of 2022 but increased in the second half of 2023.

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

SAQs are requested from key adult household members in Rounds 2 and 4. Forms that are not collected in Rounds 2 and 4 are requested again in Rounds 3 and 5. In 2023, we introduced multimode collection for SAQs. During the CAPI interview, eligible household members were notified that they would receive a link to complete their SAQ on the web. Paper SAQs were offered only if the household member did not have an email address and/or mobile phone number to which a link to the web SAQ could be sent. 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. This is shown by survey mode for the SAQs requested in 2023.

Response rates continue to decline, despite the multimode approach. In 2024, a new contact protocol for web SAQs and additional paper follow-up for web nonresponse will be implemented in an effort to increase response rates.

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In Rounds 3 and 5, key adult household members who have been diagnosed with diabetes were asked to complete a short questionnaire called the DCS. Forms not completed for pickup at the time of the interviewer’s visit were followed up on by telephone in the latter stages of Rounds 3 and 5, but unlike the SAQ, there was no follow-up in the subsequent Round for forms not collected in the Round when first requested. Response rates for the DCS for Panels 20 through 27 are shown in Table 4-18. Completion rates for the DCS showed a modest but relatively steady decline over time. In 2023, the number of DCSs requested continued to decline with a noticeable drop in response rate.

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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 2023, over 98 percent of completed cases were validated. In the spring Rounds, cases were validated using GPS data and by CARI at about the same rate. In the fall Rounds, cases were validated using GPS data at a much higher rate due to a higher proportion of in-person interviews in the fall, as opposed to CAVI or telephone interviews. CAVI and telephone interviews cannot be validated using GPS data. A small percentage (8% in the spring and 4% in the fall) were validated by phone, and less than .5% of cases were validated by mail.

The percentage of each interviewer’s completed cases that were validated averaged 85.5% of completed in the spring Rounds and 93% in the fall Rounds.

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

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4.6 Security Incidents

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

In 2023, there were two confirmed laptop and three confirmed iPhone losses. There was also one reported FedEx loss of laptop, iPhone, and accessories in September that FedEx recovered in October. Over the course of the year, five additional iPhones were reported to the MEPS Help Desk as lost, but were then found by the interviewer. The password-protected laptops were shut down at the time of the loss. Since MEPS laptops are full-disk encrypted, respondent identity was not at risk. The MEPS iPhones are also password-protected. Interviewers were counseled about keeping MEPS equipment secure at all times.

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5. Home Office Support of Field Activities

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

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5.1 Preparation for Field Activities

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

Advance mailings to all respondent households were prepared and mailed by the home office staff prior to the start of data collection. Addresses were first standardized and sent through the National Change of Address (NCOA) database to obtain the most current addresses for mailing. SAQs requested in fall 2022 that were not completed were included in the advance mailing for Round 3 and Round 5 cases in the spring 2023 advance mailing. Any mail returned as undeliverable was recorded, and the appropriate supervisor was notified. Requests to re-mail the Round 1 advance package to households who reported not receiving it were prepared and mailed by home office staff.

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

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5.2 Support During Data Collection

Respondent Contacts. Respondent contacts are an important component of home office support for the MEPS data collection effort. Printed materials mailed to respondents contain an email address and toll-free telephone number that respondents can use to contact the project representative with questions and requests to make or to cancel interview appointments—respondents also could choose not to participate in the study. Home office staff received and initiated the response to all respondent contacts. They forwarded information received from respondent calls to the field supervisors, who initiated the appropriate follow-up and informed the home office of the results of their follow-up within 24 hours of notification. Table 5-1 shows the number and percentage of RUs that made calls to the respondent hotline in the spring and fall Rounds of 2019-2023. The percentage of households that called the hotline dropped in 2023, with a significant decrease in the fall Rounds.

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Table 5-2 shows the number and types of calls received on the respondent hotline during 2022 and 2023. As in prior years, a substantial portion of the Round 1 calls were for refusals. In later Rounds, there are more calls for appointments.

Table 5-2. Calls to the respondent information line, 2022 and 2023

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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/preventive care self-administered questionnaires (PSAQs) and DCSs, were receipted and sent out for TeleForm scanning.

Helpdesk Support. The MEPS CAPI Helpdesk continued to provide technical support for field interviewing activities during 2023. Helpdesk staff were available 7 days a week to help field staff resolve CAPI, field management system, transmission, laptop, and iPhone problems. Incoming calls were documented for follow-up, as needed, to resolve individual issues and to identify issues reported by multiple interviewers. The MEPS CAPI Helpdesk coordinated tracking and shipping of all field laptops, field laptop assignments, and laptop and phone repairs.

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 2021, delivered in 2023.

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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 2023, 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 2023, 11.9 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 31.4 percent in spring 2023. For fall 2023, 11.2 percent of cases received from the field included a comment, while cases with any issue totaled 25.5 percent.

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Field interviewers must select 1 of 10 categories for each comment text string. After selecting a category, CAPI provides category-specific guidance on information to include in the comment (e.g., RU member name, event date). They receive training to help identify the most meaningful category and avoid overuse of the category “Other.” Table 6-2 shows the number of comments made in each category as assigned by the NLP algorithm and confirmed by the data technicians.

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6.1.3 Transformation

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

As shown in Figure 6-1, data transformation has four distinct layers. The metadata layer contains all the variable definitions—including names, tables, or segments or blocks—and transformation logic, sometimes known as “plain-language transformation specifications.” The analytic group leads at Westat are typically responsible for the metadata and the transformation logic.

Figure 6-1. Blaise to Dex transformation

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

Based on the metadata, two specifications are developed. The first describes the Dex structure using a formal schema, which is expressed as a set of SQL statements to create the empty Oracle Dex database. The second specification is the detailed transformation specification. Each variable is assigned to a set of similar variables called a “transformation class.” A unique transformation class is defined by the information needed to specify the transformation. For instance, some variables simply need to be copied to an appropriate location in the Dex. These are known as passthrough variables and belong to the “passthrough” class. “Code All That Apply” variables are transformed based on the value 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 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. Next, the format is transformed from the Blaise format to Oracle, writing to the single-round database (SRD). The single-round structure is necessary because the data collection instrument does not contain all data for all Rounds for a given case; rather, only the data required to field the case in that specific Round are included. The SRD data are then merged into the existing data, yielding a cumulative multi-round database (MRD).

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

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6.1.4 TeleForm/Data Editing of Scanned Forms

TeleForm, a commercial off-the-shelf software system for intelligent data capture and image processing, was used in 2023 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, including follow-up hard-copy-only in spring 2024, 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 and occupation; and
  
  
• Geographic identifiers.

Medical Conditions and Prescribed Medicine Coding

In 2023, coding was performed on the medical conditions and prescribed medicine text strings reported by household respondents for calendar year 2022. An automated system enabled coders to easily search for and assign the appropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code (for conditions) or Generic Product Identifier (GPI) code (for medicines). The system supports the verifier’s review of all codes and, as needed, correction of the coder’s initial decision. For the prescribed medicine coding, a pharmacist provided a further review of text strings questioned by the verifier, uncodable text strings, foreign medicines, and compound drugs. All coding actions were tracked in the systems, and error rates were calculated weekly. Both the condition and prescribed medicine coding efforts were staffed by three coders.

Medical conditions text strings for data year 2022 were coded to include the greatest specificity indicated by the text string. The fully specified ICD-10 code is needed to accurately match to the Clinical Classification Software Refined (CCSR) diagnosis codes. A total of 2,715 unique strings were manually coded, and the authority table was constructed with AHRQ-approved code assignments. The overall error rate for coders was 1.8 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 50 percent each year. The matching programs are reviewed and approved each year. A total of 2,503 strings were manually coded from the 2022 data year.

In a process similar to condition text strings, the prescription medicine text strings undergo two Rounds of deduplication to identify the unique strings to be coded. AHRQ’s exact and inexact matching programs are then run to further reduce the number of strings to be coded. In the spring of 2022, the prescribed medicine pick list and search tool was integrated into the CAPI instrument, which impacted the number of strings that need manually coding in 2023. The overall coding error rate (across all coders) was less than 1 percent, which is lower than the contractual goal of 2 percent. As with conditions, all prescription text strings/codes were reviewed by a verifier, with additional review of selected strings provided by a pharmacist.

Source of Payment Coding

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

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

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

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

SOP coding during 2023 was for the payment sources reported for 2022 events. For cases when the bill was paid by a source identified in response to a direct question about payment (REIMNAM), a total of 1,746 previously coded sources of payment text strings were reviewed and updated as needed. After deduplication of the strings reported for 2022, coders reviewed and coded 1,718 strings. If the bill was sent to a source other than the respondent and the respondent names that source (WHOBILL1), coders reviewed and coded 2,997 strings. For text strings reported as direct payers for prescription medicine (SRCNAME), 447 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 U.S. Census Bureau’s Demographic Surveys Division’s computer-assisted industry and occupation (I&O) codes, which can be cross-walked to the 2007 North American Industrial Classification System (NAICS) and the 2010 Standard Occupational Classifications (SOC) system. The codes characterize the jobs reported by household respondents and are released annually on the full-year (FY) JOBS file. During 2023, 11,282 jobs were coded for the 2022 JOBS file.

Geographic Coding

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

During the calendar year 2023 coding cycle, 16,168 unique address records for full-year reporting units were processed.

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6.2 Data Delivery

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

The Oracle system has a separate database for each data year. The MEPS 2023 database contains Panels 27 and 28.

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

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

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

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6.2.1 Variable Construction

Analytical groups at AHRQ work with Westat analysts to define the variables of interest for inclusion on the PUF and other key data deliveries. Variables are named according to standard naming conventions, and once the list is approved, descriptive specifications are written to define each variable and to provide detailed information for programming.

Specifications are written at two levels. The high-level specification is a descriptive specification intended to document the concept of the variable and provide high-level information regarding the variable construction requirements. The detailed-level specifications contain the details required to develop programming code for building the variables. Specifications are written and sent to AHRQ for approval. Once approval is received for the specification, program development can proceed for that variable.

Specifications guide programming development, and once programs have been written, code reviewers compare newly developed code against specifications to identify problems in either code or specifications. This program development process includes a number of steps and checkpoints to ensure that all new programs meet all specification requirements:

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

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

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6.2.2 File Deliveries

Public-Use File Deliveries

The principal files delivered during calendar year 2023 are listed below:

• Full-Year 2021 Population Characteristics file
  
  
• Full-Year 2021 Use and Expenditure file
  
  
• Full-Year 2021 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 2021 Expenditure Event files for events not included in the MPC data collection, including dental events, office-based nonphysician events, and other medical expenses
  
  
• Full-Year 2021 Prescribed Medicines Expenditure file
  
  
• Full-Year 2021 Medical Conditions file
  
  
• Full-Year 2021 JOBS file
  
  
• 2021 Food Security file
  
  
• Full-Year 2021 Appendix to MEPS Event files
  
  
• 2021 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 2023 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 2023 for MPC collection of data about 2022 health events, Westat again deduplicated the sample of providers. This process, developed in consultation with AHRQ, was designed to reduce the number of duplicate providers reported from the household data collection.

Early in 2023, following completion of MPC data collection and processing for 2021 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 2021 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 the field management system counts and operational reports detailing the fielded sample.

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

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