Review of Existing Data Sources to Assess the Impacts of the Affordable Care Act Medicaid Expansions: Working Paper. Data Gaps--Impacts on Providers

04/01/2012

With regard to hospitals, none of the available data sources included information on any of the measures of willingness to accept Medicaid patients. In addition, availability of indicators that may affect willingness to accept Medicaid is also limited: only the AHA and NAPH surveys include information on actual payer mix (although some other sources have information on charges or patient mix); in addition, availability of information on financial margins is limited to these two sources and Medicare cost reports. None of the data sources reviewed includes information on Medicaid payment rates relative to other payers. Finally, with regard to evidence of expanded, new, or terminated programs, several sources can provide evidence of changes in volume of services provided, but only the AHA data can be used to track changes in provider capacity.

For other types of providers, more information is available about willingness to accept Medicaid patients, but the information is still limited. Only NAMCS and UDS include information about payer mix, and information on financial margins is available only from UDS. Finally, the information about changes in service volume or capacity is also quite limited from non-hospital providers--indicators related to substance abuse are available from UDS and NSSATS, and UDS includes some additional indicators related to social support services and outreach. None of the data sources includes information on Medicaid payment rates relative to other payers.

TABLE 2. Outcome Indicators for Impacts on Individuals
Topic Indicators
Health insurance coverage For individuals and family units: point in time coverage, by type of coverage; "ever during the year" coverage, by type of coverage; length of time covered during the year, by type of coverage; intermittent coverage/churning during the year, by type of coverage
Health care access and use
   Usual source of care (USOC) Whether the individual has a USOC; type of place for USOC; characteristics of USOC; whether the individual has a personal doctor or health care provider; USOC medical home indicators; USOC night/weekend hours; difficulty reaching USOC after hours, in person, or by telephone
   Use of health care services Use of services by type of visit/provider; use of service by type of care (e.g., vaccinations, preventive care); substance abuse counseling/treatment; mental health services; receipt of recommended preventive care/counseling services (blood cholesterol check, blood pressure check, blood tested for high blood sugar, mammogram, Pap test, flu shot, counseling on benefits of diet/exercise, counseling on risks of smoking)
   Unmet need/barriers to care/ease of obtaining care Any unmet need for care; specific types of unmet need; unmet need due to cost; unmet need due to provider capacity/availability; ability to get care as soon as needed; ability to get routine appointments when needed; ability to get needed tests or treatments; ability to see necessary specialist; got all needed care; got all needed drugs; difficulty finding a doctor who would see you; told by doctor's office/clinic that they wouldn't accept you as new patient; told by doctor's office/clinic that they wouldn't accept your type of health insurance
Patient experience Communication; respect; adequacy of time spent; perception of quality of care received; satisfaction with care
Cost and affordability
   Total medical cost Total health care spending; spending by type of service; spending by payer
   Out of pocket cost Out of pocket premiums (total and as percentage of income); out of pocket health care costs (total and as percentage of income)
   Financial strain Financial strain (owe money for medical bills, borrowed money or skipped bills to pay medical bills, refused treatment because of medical debt)
Health outcomes
   Health status Self-reported health status (general, physical, and mental health); number of days of good physical health; number of days of poor mental health; number of days impaired by poor physical/mental health; screens positive for depression
   Undiagnosed or untreated health conditions Undiagnosed conditions (e.g., hypertension, high cholesterol, diabetes); untreated/unmanaged conditions; untreated depression
   Health behaviors Diet, physical activity
   Potentially preventable or avoidable health care utilization Hospital re-admissions; preventable or avoidable emergency department visit; hospital stay for ambulatory care sensitive condition
Receipt of other government assistance Cash assistance: Temporary Assistance for Needy Families, Supplemental Security Income; food assistance: Supplemental Nutrition Assistance Program, Women, Infants and Children; housing assistance
Demographic and control variables Income; functional limitations; body mass index/obesity; condition specific measures (e.g., diabetes, asthma); educational attainment; work status; marital status/living arrangement; age; race/ethnicity; language; birthplace/citizenship; type/stability of housing arrangement; ever been homeless or had to "double up"; presence of car

 

TABLE 3. Outcome Indicators for Impacts on Providers
Topic Indicators
Willingness to accept Medicaid patients Accepts all Medicaid patients
Accepts previous enrollees, but not new enrollees
Not accepting new Medicaid patients, but accepting new private patients  
Indicators that may affect willingness to accept Medicaid   Payer mix
Medicaid payment rates (e.g., relative to Medicare)
Margins/financial status
Evidence of expanded, new, or terminated programs Substance abuse and mental health treatment programs
Emergency department visits
Social support services
Outreach

 

TABLE 4. Survey Sample Sizes for Key Groups of Interest, Population Age 19-64
  Total   Income at  
or Below
138% FPL
  Income at  
or Below
50% FPL
Substance
  Dependence  
or Abuse
  Substance Dependence  
or Abuse and
Income Below
138% FPL
Mental
  Illness  
  Mental Illness  
and Income
Below
138% FPL
ACS 2010 1,806,189 334,642 110,658 N/A N/A N/A N/A
CPS 2011 121,520 23,368 7,115 N/A N/A N/A N/A
NHIS 2010 54,177 full file;
  21,396 sample adults  
13, 349 full file;
  5,811 sample adults  
3,471 full file;
  1,684 sample adults  
N/A N/A N/A N/A
MEPS 2009 21,596 5,502 1,415 N/A N/A N/A N/A
SIPP 2010a 52,524 11,593 4,019 N/A N/A N/A N/A
BRFSS 2010b 292,502 55,539 16,545 N/A N/A N/A N/A
NHANES 2009-2010   4,861 1,770 380 N/A N/A N/A N/A
NSDUH 2010c 33,847 ~6,700 N/A 4,849 ~1,146 4,169 ~1,113
SOURCES: State Health Access Data Assistance Center (SHADAC) tabulations from public use files for ACS, CPS, NHIS, MEPS, SIPP, BRFSS, and NHANES. NSDUH counts obtained using online data analysis tool at http://www.icpsr.umich.edu/icpsrweb/SAMHDA/sdatools/resources.
ACS = American Community Survey; BRFSS = Behavioral Risk Factor Surveillance System; CPS = Current Population Survey; FPL = federal poverty level; MEPS = Medical Expenditure Panel Survey; N/A = not available; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSDUH = National Survey on Drug Use and Health; SIPP = Survey of Income and Program Participation.
  1. Sample sizes are for Wave 6 of the 2008 SIPP panel. Income is estimated using the first month in each rotation group in Wave 6.
  2. Estimated based on categorical income and household size.
  3. Income measure in NSDUH public use file is below 100% of poverty. Substance dependence or abuse indicator is for alcohol OR illicit drug dependence OR abuse in the past year. Mental illness indicator is for serious or moderate mental illness in the past year.

 

TABLE 5. Measures of Health Insurance Coverage from Population Surveys
  ACS
  2011  
  CPS ASEC  
2011
  NHIS  
2011
  MEPS  
2009
SIPP
  2008 Panel  
  BRFSS  
2011
NHANES
  2009-10  
  NSDUH  
2010
Point in time coverage type
Individual, by type of coverage X   X X X insured/ uninsured X X
Family unit, by type of coverage X   X X X      
"Ever during the year" coverage type
Individual, by type of coverage   all coverage types except uninsured ever uninsured X X   ever uninsured ever uninsured
Family unit, by type of coverage   all coverage types except uninsured ever uninsured X X      
Length of time during year by coverage type
Individual, by type of coverage   uninsured all year; # of months covered by Medicaid length of time uninsured X X     length of time uninsured
Family unit, by type of coverage   uninsured all year; # of months covered by Medicaid length of time uninsured X X      
Intermittent coverage/churning during year
Individual, by type of coverage   for Medicaid, # of months covered ever uninsured; if covered all year, same coverage type all year?* X X   ever uninsured ever uninsured
Family unit, by type of coverage   for Medicaid, # of months covered ever uninsured; if covered all year, same coverage type all year?* X X      
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires.
ACS = American Community Survey; BRFSS = Behavioral Risk Factor Surveillance System; CPS ASEC = Current Population Survey Annual Social and Economic Supplement; MEPS = Medical Expenditure Panel Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSDUH = National Survey on Drug Use and Health; SIPP = Survey of Income and Program Participation.
*Question about same coverage type for all of past year was added in 2011.

 

TABLE 6. Measures of Health Care Access and Use from Population Surveys
  ACS
  2011  
  CPS ASEC  
2011
  NHIS  
2011
  MEPS  
2009
SIPP
  2008 Panel  
  BRFSS  
2011
NHANES
  2009-10  
  NSDUH  
2010
Usual source of care
Usual source of care     X X     X  
Type of place for usual source of care     X X     X  
Characteristics of usual source of care                
   Personal doctor/provider       X   X    
   Medical home indicators                
   Night/weekend hours       X        
   Difficulty reaching after hours       X        
   Difficulty reaching in person                
   Difficulty reaching by phone       X        
Health care use
By type of visit/provider     X X X   X X
By type of care (e.g., vaccinations, preventive care)     X X        
Substance abuse counseling/treatment       X       X
Mental health services     X X     X X
Receipt of recommended preventive care/counseling                
Blood cholesterol checked     X X   X X  
Blood pressure checked     X X        
Blood tested for high blood sugar     X X   state option X  
Mammogram     X X   state option    
Pap smear     X X   state option    
Flu shot     X X   X    
Benefits of diet/exercise     X X        
Risks of smoking     X X        
Unmet need/barriers to care/ease of obtaining care
Any unmet need*     X X X      
Specific types of unmet need       dental, Rx dental     substance abuse/
mental health
Unmet need due to cost     X X   X   substance abuse/
mental health
Unmet need due to provider capacity/availability               X
Ability to get care as soon as needed       X        
Ability to get routine appointments when needed       X        
Ability to get needed tests or treatments       X        
Ability to see necessary specialist       X        
Got all needed care                
Got all needed drugs                
Difficulty finding a doctor who would see you     X^          
Told by dr office/clinic that that wouldn't accept you as new patient     X^          
Told by dr office/clinic that wouldn't accept your type of health insurance     X^          
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires.
ACS = American Community Survey; BRFSS = Behavioral Risk Factor Surveillance System; CPS ASEC = Current Population Survey Annual Social and Economic Supplement; MEPS = Medical Expenditure Panel Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSDUH = National Survey on Drug Use and Health; SIPP = Survey of Income and Program Participation.
*Unmet need defined as care not received (does not include delayed care).
^ Question added in 2011.

 

TABLE 7. Measures of Patient Experience from Population Surveys
  ACS
  2011  
  CPS ASEC  
2011
  NHIS  
2011
  MEPS  
2009
SIPP
  2008 Panel  
  BRFSS  
2011
NHANES
  2009-10  
  NSDUH  
2010
Patient experience
Communication       X        
Respect       X        
Adequacy of time spent       X        
Perception of quality of care received       X        
Satisfaction with care                
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires.
ACS = American Community Survey; BRFSS = Behavioral Risk Factor Surveillance System; CPS ASEC = Current Population Survey Annual Social and Economic Supplement; MEPS = Medical Expenditure Panel Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSDUH = National Survey on Drug Use and Health; SIPP = Survey of Income and Program Participation.

 

TABLE 8. Measures of Cost and Affordability from Population Surveys
  ACS
  2011  
  CPS ASEC  
2011
  NHIS  
2011
  MEPS  
2009
SIPP
  2008 Panel  
  BRFSS  
2011
NHANES
  2009-10  
  NSDUH  
2010
Cost
Total health care spending       X        
Spending by type of service       X        
Spending by payer       X        
Burden of health care spending on individual and family
Out of pocket premiums:                
Total   X X* X X      
As percentage of income   X X X X      
Out of pocket health care costs:                
Total   individual and family family individual and family individual and family     Individual-- mental health
As percentage of income   X X X X     X
Financial strain (owe money for medical bills, borrowed money or skipped bills to pay medical bills, refused treatment because of medical debt)     family**          
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires.
ACS = American Community Survey; BRFSS = Behavioral Risk Factor Surveillance System; CPS ASEC = Current Population Survey Annual Social and Economic Supplement; MEPS = Medical Expenditure Panel Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSDUH = National Survey on Drug Use and Health; SIPP = Survey of Income and Program Participation.
*People covered by private insurance at the time of the survey
**Question added in 2011

 

TABLE 9. Measures of Health Outcomes from Population Surveys
  ACS
  2011  
  CPS ASEC  
2011
  NHIS  
2011
  MEPS  
2009
SIPP
  2008 Panel  
  BRFSS  
2011
NHANES
  2009-10  
  NSDUH  
2010
Self-reported health status:
General health   X X X X X X X
Physical health                
Mental health       X        
Number of days of good physical health       X   X X  
Number of days of poor mental health       X   X X  
Number of days impaired by poor physical or mental health       X   X X  
Screens positive for depression     X     state option X X
Undiagnosed conditions (hypertension, high cholesterol, diabetes, etc.)             X substance abuse/
mental health
Untreated/unmanaged conditions (hypertension, high cholesterol, diabetes, etc.)             X substance abuse/
mental health
Untreated depression             X X
Diet/physical activity     physical activity only     both both  
Hospital re-admissions       X        
Preventable/avoidable emergency department visit       X        
Hospital stay for ambulatory care sensitive condition       X        
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires.
ACS = American Community Survey; BRFSS = Behavioral Risk Factor Surveillance System; CPS ASEC = Current Population Survey Annual Social and Economic Supplement; MEPS = Medical Expenditure Panel Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSDUH = National Survey on Drug Use and Health; SIPP = Survey of Income and Program Participation.

 

TABLE 10. Measures of Participation in Other Government Programs from Population Surveys
  ACS
  2011  
  CPS ASEC  
2011
  NHIS  
2011
  MEPS  
2009
SIPP
  2008 Panel  
  BRFSS  
2011
NHANES
  2009-10  
  NSDUH  
2010
Cash assistance:
TANF X X X X X   X X
SSI X X X X X   X X
Food assistance:
SNAP X X X X X   X X
WIC   X X   X   X  
Housing assistance   X X   X      
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires.
ACS = American Community Survey; BRFSS = Behavioral Risk Factor Surveillance System; CPS ASEC = Current Population Survey Annual Social and Economic Supplement; MEPS = Medical Expenditure Panel Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSDUH = National Survey on Drug Use and Health; SIPP = Survey of Income and Program Participation; SNAP = Supplemental Nutrition Assistance Program; SSI = Supplemental Security Income; TANF = Temporary Assistance for Needy Families; WIC = Women, Infants and Children.

 

TABLE 11. Demographic and Control Variables for Impacts on Individuals from Populations Surveys
  ACS
  2011  
  CPS ASEC  
2011*
  NHIS  
2011
  MEPS  
2009
SIPP
  2008 Panel  
  BRFSS  
2011
NHANES
  2009-10  
  NSDUH  
2010
Income X X X X X X X X
Functional limitations X X X X X X X  
Body mass index/obesity     X X   X X  
Condition specific measures (e.g., diabetes, asthma)     X X X** X X X
Educational attainment X X X X X X X X
Work status X X X X X X X X
Marital status/living arrangement X X X X X X X X
Age X X X X X X X X
Race/ethnicity X X X X X X X X
Language X     X X   X  
Birthplace/citizenship X X X X X   X X
Type/stability of housing arrangement own/rent; tenure at current address; moved in past year own/rent; moved in past year own/rent   own/rent; moved since last interview; evicted in past year*** own/rent own/rent; tenure at current address moved in past year
Ever been homeless                
Ever had to "double up"                
Presence of car X       X      
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires.
ACS = American Community Survey; BRFSS = Behavioral Risk Factor Surveillance System; CPS = Current Population Survey; MEPS = Medical Expenditure Panel Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NSDUH = National Survey on Drug Use and Health; SIPP = Survey of Income and Program Participation.
*Some of the CPS measures are included in the basic monthly survey rather than in the Annual Social and Economic Supplement.
**Questions asked for people with functional or work limitations in Wave 6 of 2008 panel.
***Eviction questions in Wave 6 of 2008 panel.

 

TABLE 12a. Provider Measures--Hospitals
  Acute Care Hospitals   Safety Net  
Hospitals
  NHAMCS     AHA     NHDS     HCUP   Medicaid
  Cost Report  
NAPH
Willingness to accept Medicaid patients
Accepts all Medicaid patients            
Accepts previous enrollees, but not new enrollees            
Not accepting new Medicaid patients, but accepting new private patients            
Indicators that may affect willingness to accept Medicaid
Payer mix patient mix X patient mix and charges patient mix and charges patient mix X
Medicaid payment rates (e.g., relative to Medicare)            
Margins/financial status   X     X X
Evidence of expanded, new, or terminated programs across various provider types
Substance abuse and mental health treatment programs X** X X** X**    
Emergency department visits X** X   X**   X**
Social support services            
Outreach strategies            
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires.
AHA = American Hospital Association; HCUP = Healthcare Cost and Utilization Project; NAPH = National Association of Public Hospitals and Health Systems; NHAMCS = National Hospital Ambulatory Medical Care Survey; NHDS = National Hospital Discharge Survey.
**Evidence of service utilization, but no information on provider capacity.

 

TABLE 12b. Provider Measures--Physicians, Community Health Centers, and Substance Abuse Treatment Facilities
  Physicians Community Health Centers Substance Abuse
Treatment Facilities
  NAMCS     AMA     NAMCS     UDS     TEDS     N-SSATS  
Willingness to accept Medicaid patients
Accepts all Medicaid patients accepting any new Medicaid patients   accepting any new Medicaid patients     *
Accepts previous enrollees, but not new enrollees           *
Not accepting new Medicaid patients, but accepting new private patients X   X     *
Indicators that may affect willingness to accept Medicaid
Payer mix X   X X patient mix  
Medicaid payment rates (e.g., relative to Medicare)            
Margins/financial status       X    
Evidence of expanded, new, or terminated programs across various provider types
Substance abuse and mental health treatment programs       X incomplete**^ X
Emergency department visits            
Social support services       X    
Outreach strategies       X    
SOURCE: State Health Access Data Assistance Center (SHADAC) review of survey questionnaires. AMA = American Medical Association Physician Masterfile; NAMCS = National Ambulatory Medical Care Survey; N-SSATS = National Survey of Substance Abuse Treatment Services; TEDS = Treatment Episode Data Set; UDS = Uniform Data System reports submitted to the Health Resources and Services Administration.
*Includes information on payment types accepted but not willingness to accept new patients.
**Evidence of service utilization, but no information on provider capacity.
^TEDS data do not provide a complete picture of substance abuse and mental health treatment services, because only providers that receive federal and state funding are required to report.

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