Using Adjusted MEPS Data to Study Incidence of Health Care Finance

1
Using Adjusted MEPS Data to Study Incidence of
Health Care Finance

• Thomas M. Selden
• Division of Modeling Simulation
• Center for Financing, Access and Cost Trends

2
Advantages of HH Survey Data

• Only HH survey data possess the correlations
  across variables necessary for
• Behavioral research
• Subgroup or distributional estimates
• Policy simulations

3
Using MEPS to Study Finance Incidence

• Prevalence and distribution of high out-of-pocket
  burdens
• Overall population (Banthin and Bernard, JAMA)
• Within-year burdens (Selden, HSR)
• Policy impacts (Banthin and Selden, Inquiry
  Selden, Kenney, et al., Health Affairs)
• Distribution of benefits from public spending
• Selden and Gray (Health Affairs)
• Selden and Sing (Health Affairs)
• Progressivity of the financing of health care
• Selden (preliminary)

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Potential Issues with Using Unadjusted MEPS

• Out-of-scope populations
• Institutionalized persons not in MEPS
• Out-of-scope expenditures
• Personal care
• Differential attrition (high-cost cases)
• Under-reporting of use
• Lump-sum payments to providers
• MCR/MCD grants to hospitals for teaching/needy
• Tax subsidies for coverage and care

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Presentation Overview

• Present step-by-step results from efforts at AHRQ
  to adjust MEPS to
• Include tax subsidies
• Align with National Health Expenditure Accounts
• Show some applications
• burdens
• benefit incidence analysis
• equity in financing of health care finance and use

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MEPS Data

• Over 30,000 persons in over 10,000 households
• Every year since 1996
• Civilian noninstitutionalized population
• Households report use and expenditures during 5
  in person interviews over 2 years
• Supplemented by journal entries and follow back
  survey of providers
• Compared to CMS NHEA every 5 years when
  availability of Census data on providers
  facilitates alignment (last done in 2002)

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Apples to Apples Comparison of MEPS NHEA, 2002
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MEPS-Consistent NHEA Personal Health Care, 2002

• x

Source Selden and Sing (2008a)
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MEPS-Consistent NHEA Personal Health Care, 2002
(cont)

• Producing this chart is a lot of work!
• Aligning service definitions
• Hospital-owned home health services
• Physician and clinical services (allocated to
  Physician vs. Other professional as in MEPS)
• LTC estimates
• Acute care of LTC residents
• Hospital-owned nursing homes
• All adjustments by sources of payment and type of
  service...

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Closing the 13 Gap with MEPS-Consistent NHEA PHC

• Step 1 Account for wider public coverage gap by
  upweighting persons with Medicaid/CHIP coverage
• 10 percent increase
• Brings enrolled population into alignment with
  administrative enrollment counts
• Raking post-stratification used so that
  adjustment does not change full MEPS distribution
  of age, race, sex, Medicare enrollment, and
  uninsurance (so adjustment in essence entails
  modest reduction in private coverage)

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Closing the 13 Gap with MEPS-Consistent NHEA PHC

• Step 2 Account for differential attrition of
  high-cost cases
• upweighted top 3 percent of distribution by major
  insurance group (by average of 18)
• adjustment justified by analyses of claims data
  (public and private)
• upweighting used raking post-stratification to
  preserve distribution by age, race, sex, poverty,
  coverage, region
• closed 37 of the gap

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Closing the 13 Gap with MEPS-Consistent NHEA PHC

• Step 3 Close remaining gap
• Allocate lab test gap according to physician
  visits
• Scale remaining expenditures
• Brings MEPS up from 881B to 964B

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Out-of-Scope PHC Spending
Note Useful for reform simulations that would,
say, cover uninsured or increase/decrease
Medicaid population
14
Non-PHC Spending
Note Useful for benefit incidence and equity
analyses
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Application Reform Simulations

• NHEA-aligned MEPS data is at the heart of health
  reform simulations
• Improves on situation in early 1990s, when
  simulations of previous health reforms differed
  largely due to different starting points
• Projected NHEA-aligned MEPS

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Application 20 Burden Frequency among
Nonelderly with Private Insurance With and
without Adjusting for Tax Expenditures, 2002
Source Selden (IJHCFE, 2008)
17
Tax Expenditure Effect on Burdens is Small,
Compared to Within-Year Burdens and
Cost-Sharing in Public Coverage for Children
Source Selden (HSR, 2009)
Source Selden et al. (HA, 2009)
18
Application Benefit Incidence Analysis of
Public Spending
80 of health care spending for persons in poor
health paid by public sector
Source Selden and Sing (Health Affairs, 2008)
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Benefit Incidence (cont.)
Nearly half of all health care in highest
income group paid by public sector
Source Selden and Sing (Health Affairs, 2008)
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Application Equity in Health Care Finance, 2002
21
Average Combined Burdens by Financing Source and
Income Decile
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Conclusion

• Adjusting MEPS to peg NHEA benchmarks and capture
  tax expenditures is a painstaking endeavor
• The result, however, is a powerful tool for
  reform simulations and equity analyses

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Bibliography

• Banthin and Bernard (2006) Changes in Financial
  Burdens for Health Care National Estimates for
  the Population Younger Than 65 Years, 1996 to
  2003, JAMA, v. 296, n. 22 2712-2719.
• Selden and Banthin (2003) The ABC's of children's
  health care How the Medicaid expansions affected
  access, burdens, and coverage between 1987 and
  1996, Inquiry 40133-45.
• Selden, Kenney, Pantell, Ruhter (2009) Cost
  Sharing In Medicaid And CHIP How Does It Affect
  Out-Of-Pocket Spending? Health Affairs
  (http//content.healthaffairs.org/cgi/content/abst
  ract/hlthaff.28.4.w607)

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Bibliography (cont.)

• Selden (2009) The Within-Year Concentration of
  Medical Care Implications for Family
  Out-of-Pocket Expenditure Burdens, Health
  Services Research, 44(3)1029-1051.
• Selden and Gray (2008b) Tax Subsidies For
  Employment-Related Health Insurance Estimates
  For 2006, Health Affairs (http//content.healthaff
  airs.org/cgi/content/abstract/25/6/1568)
• Selden (2008) The effect of tax subsidies on high
  health care expenditure burdens in the United
  States, International Journal of Health Care
  Finance and Economics, v. 8 209-223.

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Bibliography (cont.)

• Selden and Sing (2008a) Aligning the Medical
  Expenditure Panel Survey to Aggregate U.S.
  Benchmarks, MEPS Working Paper (http//www.meps.ah
  rq.gov/mepsweb/data_stats/Pub_ProdResults_Details.
  jsp?ptWorking20Paperopt2id862)
• Selden and Sing (2008b) The Distribution Of
  Public Spending For Health Care In The United
  States, 2002, Health Affairs (http//content.healt
  haffairs.org/cgi/content/abstract/hlthaff.27.5.w34
  9v1)
• Selden, Equity in the Finance and Delivery of
  Health Care in the United States (unpublished)