HHS currently conducts multiple provider-based surveys, including components of NCHS' National Health Care Survey (hospitals, physicians, nursing homes, ambulatory surgery, and home and hospice care), the provider followup components of NMES, and the Healthcare Cost and Utilization Project. Moving beyond measures of capacity and infrastructure, these surveys measure the utilization of services by quantifying the types of diagnoses and services provided.
HHS' basic approach:
• In instances where multiple HHS surveys approach the same class of providers, efforts will be consolidated operationally so that there are common field staff, procedures, computer-assisted survey software, and post-processing capabilities.
• A common core questionnaire will be identified for use in surveys that would approach each type of provider.
• Common classification systems, standards, procedure coding, etc., will be adopted that would maximize efficiency as well as enhance data comparability and analytic utility.
Consensus has been reached on consolidation of the components of the National Health Care Survey and the provider followup components of the MEP. Additional steps will be taken to evaluate the extent to which other efforts, such as the Healthcare Cost and Utilization Project, the Drug Abuse Warning Network (DAWN), and the institutional component of the MCBS can be integrated into this framework.
A pending RFP for the continuation of DAWN provides for theredesign of DAWN. The redesign will be done in stages, with initial steps including extensive evaluation of the current design,determination of current data needs, and consultation with survey design experts and DAWN data users. The redesign issues that will be addressed are completely open, but it is anticipated that the scope of the survey, definitions of cases, sampling methods, and possible consolidation with other ongoing Federal government surveys will be studied. Later stages of the redesign will include conducting a pilot test and implementing the new design, assuming agreement is reached during the initial phase regarding the appropriate design.
Surveys of Nursing Homes and Related Institutions
Shortcomings with current surveys of nursing homes and related institutions include:
• The MCBS-institutional survey, while providing use and expenditure data for both nursing home residents and residents in personal care homes, is limited to a relatively small sample size of 1,000 individuals who are Medicare beneficiaries. The small sample size does not permit analysis for some subgroups of particular policy interest (e.g. individuals under the age of 65, minority populations), nor does the sample capture the non-Medicare population.
• The NNHS includes all residents of nursing homes (Medicare and non-Medicare eligible) as well as residents of personal care homes. Unlike MCBS and NMES-NNHES, the NNHS does not collect expenditure data; unlike NMES-NNHES the NNHS does not include a survey of the next-of-kin to collect information on family assets and community-based network of potential care givers.
• NMES-NNHES also is limited to nursing homes and does not include a sample of residents from personal care homes. While it does collect both use and expenditure data as well as data from the next of kin, the current design is relatively expensive in comparison to either MCBS or NNHS (approximately $14 million as compared to $1 or $1.5 million).
The proposed nursing home survey component of the Consolidated Survey would be collected every five years and jointly satisfy the analytical objectives of the respective AHCPR NMES III National Nursing Home Expenditure Survey and the NCHS National Nursing Home Survey. The survey design would be modelled to facilitate calendar-year use and expenditure estimates. The sample of facilities would be increased from 800 to 1,200 to satisfy precision requirements for facility level characteristics, while the sample of residents would remain at the level specified for the NMES III survey (3,200 residents in facilities at the start of the survey year and 2,400 first admissions over the course of the survey year). Data on the capacity, staffing, and services provided by the institutions would also be collected.
This sample of institutionalized residents would be coordinated with the institutional sample selected from the MCBS sample. Approximately 1,000 residents would be followed longitudinally across multiple years according to the MCBS data collection plan.
The design would include a more frequent survey of institutions, conducted in years between the full survey, to obtain necessary data on the capacity, staffing, and services provided by the institutions.
Survey Design Enhancements
To obtain complete annual profiles of health care expenditures at the person level, individuals sampled from the household component of the Consolidated Health and Health Economic Survey who entered long-term care facilities would be followed (approximately 250 individuals annually), and their institutional use and expenditure data collected. This is consistent with the current MCBS approach. This annual sample of institutional users selected from the MEP would be combined with the MCBS institutional sample to increase the precision of survey estimates that characterize the institutional population over levels currently attained through the MCBS. The current NMES III survey restricts coverage of the institutional population to individuals in nursing homes. The scope of the survey will be enhanced to attempt to represent individuals who reside in board and care homes.
Consolidated Design Features
The institution-based consolidated health survey would incorporate the data collection efforts for the NNHS, and NMES-NNHES into one effort, closely coordinated with the MCBS (institutionalized population) with the following features:
• a longitudinal design, in which nursing home residents would be followed for a period of 16 months (similar to NMES-NNHES), but with one less core round of data collection (from 4 to 3 core rounds) for the Consolidated Nursing Home Survey;
• a sample of 1,200 facilities; this sample would be merged analytically with the facilities associated with the MCBS institutional sample;
• a sample of 3,200 residents at the start of the calendar year and 2,400 new admissions over the course of the calendar year; this sample would be merged analytically with the MCBS sample of approximately 1,000 institutionalized residents that are surveyed each year;
• a single questionnaire and data collection effort which satisfies the analytic capabilities of the individual data collection efforts; and
• data collection repeated every five years.
Consolidated Design Efficiencies
The consolidated design reflects the following reductions in burden and associated costs:
• a significant reduction in the facility and resident sample sizes from the targets considered in the individual NCHS and AHCPR planned surveys;
• associated reduction in annual data collection costs;
• efficiencies with respect to questionnaire design and implementation, similar to those noted for the household consolidated effort; and
• efficiencies with respect to post-data processing (editing, imputation, weighting, production of analytic data files), similar to those discussed for the household consolidated effort.
Expanded and Enhanced Analytic Capabilities
The consolidated design provides the analytic capability to:
• examine the health status, medical care use and associated expenditures for nursing home residents over the course of a year, paralleling the data available for the noninstitutionalized population;
• assess the size of the Medicare-population institutionalized in personal care homes and explore the feasibility of using the Medicare beneficiary sample to identify personal care homes for estimating personal care home use by non-Medicare beneficiaries;
• examine acute care use (e.g., hospitalizations) for institutionalized individuals; and
• examine nursing home use for the non-Medicare population and changes in utilization by this population over time (a growing sector of the nursing home population).
Surveys of Hospitals
NCHS currently conducts the National Hospital Discharge (NHDS) as part of the National Health Care Survey. The NHDS is based on a list sample of hospitals, and discharge records for a sample of patients are abstracted to obtain data including diagnosis, surgical and other procedures, etc. The NMES medical provider study follows individuals in the household sample to hospitals where they obtained treatment, obtaining data similar to the NHDS but also including financial information.
Under the HHS plan, these surveys would be consolidated so that:
• Providers are identified from list frames or inventories and by respondents in the MEP;
• A single field agent will be used to collect data from hospitals;
• A common core of questions would be obtained from patient records regardless of which sample was used; and
• Gains would be achieved with respect to questionnaire design, training and fielding of interviewers, editing, imputation, and data based development.
Additional study will be given to the relationship of the Healthcare Cost and Utilization Project, which obtains data from State-wide discharge systems, to this consolidated activity.
Consolidated Design Efficiencies
Similar efficiencies to the nursing home component will be realized, including reduction in cost of field operations, savings in questionnaire design and implementation, and efficiencies in post-data processing.
Non-hospital Medical Care Providers
For NAMCS, NHAMCS, NHHCS, NSAS, and for portions of the NMES-MPS that approach hospital-based and office-based physicians and ambulatory surgery:
• Providers are identified from list frames or inventories and by respondents in the MEP.
• A single field agent will be used to collect data from all providers in these categories.
• A common core of questions will be asked of each provider. In addition, more detailed charge information will be obtained for the sample derived from the MEP and more detailed information concerning the content of care delivered will be asked on the broader sample.
• If feasible, multiplicity estimators can be used to combine the data from both frames.
• Gains will be achieved with respect to questionnaire design, training and fielding of interviewers, editing, imputation, and data based development.
The same approach will be explored for other provider surveys conducted by HHS, such as the Drug Abuse Warning Network (DAWN). A contract is currently being prepared by SAMHSA for the next cycle of DAWN, with the first phase of the contract being an evaluation of alternate means through which the data might be collected.