The Quality of Reporting on The Quality of Reporting on Race & Ethnicity in Medicare Data: Race & Ethnicity in Medicare Data:

Assessing the Effect of Improved CodingAssessing the Effect of Improved Coding

Ernest Moy, Linda G. GreenbergErnest Moy, Linda G. Greenberg

Center for Quality Improvement Center for Quality Improvement and Patient Safetyand Patient Safety

The analytic database was created by the Research Triangle Institute (RTI) for CMS and AHRQ under CMS Contract Number: 500-00-0024, Task No. 8 (2005) and an AHRQ/CMS Interagency Agreement

CMS Contract Number 500-00-0024 Task No. 21 (2006).

BackgroundBackground

Assessing health care disparities is Assessing health care disparities is often hindered byoften hindered by1.1. Small samplesSmall samples

2.2. Lack of detailed geographic informationLack of detailed geographic information

3.3. Inaccurate racial identificationInaccurate racial identification

4.4. Lack of socioeconomic informationLack of socioeconomic information

Medicare administrative data can Medicare administrative data can address address 11 & & 22 but need enrichment to but need enrichment to address address 33 & & 44

Project GoalsProject Goals

Builds on project to enrich Medicare data Builds on project to enrich Medicare data & allow better disparities assessments& allow better disparities assessments– Enrich identification of Hispanics & AsiansEnrich identification of Hispanics & Asians

– Add information on socioeconomic statusAdd information on socioeconomic status

Quantifies impact of improved coding Quantifies impact of improved coding compared with standard Medicare compared with standard Medicare enrollment database (EDB) codingenrollment database (EDB) coding

Methods for Improving DataMethods for Improving Data

Identification of Hispanics & AsiansIdentification of Hispanics & Asians– Enriched racial coding of enrollment Enriched racial coding of enrollment

database using combination of surname, first database using combination of surname, first name, and State of residencename, and State of residence

– Validated against self-reported race data Validated against self-reported race data (Medicare Current Beneficiary Survey)(Medicare Current Beneficiary Survey) Sensitivity Sensitivity improved dramaticallyimproved dramatically

Hispanics from 30% to 77%Hispanics from 30% to 77% Asians from 55% to 80%Asians from 55% to 80%

Specificity unchangedSpecificity unchanged

Methods for Improving DataMethods for Improving Data

Added area SES info at block group levelAdded area SES info at block group level– % labor force unemployed% labor force unemployed

– % people living below poverty level% people living below poverty level

– Median household incomeMedian household income

– Median value of dwellingsMedian value of dwellings

– % adults w/ < high school education% adults w/ < high school education

– % adults w/ 4+ years of college% adults w/ 4+ years of college

– % households w/ >1 person per room% households w/ >1 person per room

Created SES indexCreated SES index Sorted people by index into quartilesSorted people by index into quartiles

Enriched DatabaseEnriched Database

Significant population shiftsSignificant population shifts– Hispanics +2.0 millionHispanics +2.0 million

– Asians +260,000Asians +260,000

– Whites -1.7 millionWhites -1.7 million

– Other/Unknown -460,000Other/Unknown -460,000

Stratified sample of Medicare fee-for-Stratified sample of Medicare fee-for-service beneficiaries to allow estimates service beneficiaries to allow estimates of all racial groupsof all racial groups

Measures of Health CareMeasures of Health Care

Datasource: 2002 CMS inpatient, Datasource: 2002 CMS inpatient, outpatient, physican, & DME claimsoutpatient, physican, & DME claims

Cancer screeningCancer screening– Colorectal cancer screening (FOBT or Colorectal cancer screening (FOBT or

lower endoscopy)lower endoscopy)– MammographyMammography– Prostate specific antigenProstate specific antigen

Diabetes careDiabetes care– Diabetic testing (HbA1c, lipids, urine)Diabetic testing (HbA1c, lipids, urine)– Eye examinationEye examination– Instruction in self-careInstruction in self-care

AnalysisAnalysis

Compared measures of health care by Compared measures of health care by – Standard Medicare race coding (EDB race)Standard Medicare race coding (EDB race)

– Enriched race coding (enriched race)Enriched race coding (enriched race)

Compared magnitude of racial Compared magnitude of racial differences compared with Non-Hispanic differences compared with Non-Hispanic whites for EDB vs. enriched racewhites for EDB vs. enriched race

Compared racial differences stratified by Compared racial differences stratified by SES for EDB vs. enriched raceSES for EDB vs. enriched race

No Colorectal Cancer Screening by No Colorectal Cancer Screening by Race: EDB vs. Enriched RaceRace: EDB vs. Enriched Race

80%

85%

90%

95%

100%

EDB

Enriched

-2%

0%

2%

4%

6%

8%

10%

No Mammography (l) & PSA (r) by No Mammography (l) & PSA (r) by Race: EDB vs. Enriched RaceRace: EDB vs. Enriched Race

-5%

0%

5%

10%

15%

20%

25%

EDB

Enriched

-5%

0%

5%

10%

15%

20%

25%

No Diabetic Testing by Race: No Diabetic Testing by Race: EDB vs. Enriched RaceEDB vs. Enriched Race

0%

10%

20%

30%

40%

50%

60%

EDB

Enriched

-5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

No Diabetic Eye Exam & Self-care Ed No Diabetic Eye Exam & Self-care Ed by Race: EDB vs. Enriched Raceby Race: EDB vs. Enriched Race

-5%

0%

5%

10%

15%

20%

25%

30%

EDB

Enriched

-5%

0%

5%

10%

15%

20%

25%

30%

No PSA by Race: EDB vs. Enriched No PSA by Race: EDB vs. Enriched Race, High (l) vs. Low SES (r)Race, High (l) vs. Low SES (r)

0%

5%

10%

15%

20%

25%

EDB

Enriched

0%

5%

10%

15%

20%

25%

Summary of EffectsSummary of Effects

Overall, almost all disparities Overall, almost all disparities underestimatedunderestimated

Asians: 4/6 measures, direction of disparity Asians: 4/6 measures, direction of disparity changedchanged

Blacks: 3/6 measures, disparity Blacks: 3/6 measures, disparity underestimated >100%underestimated >100%

Hispanics: 4/6 measures, disparity Hispanics: 4/6 measures, disparity underestimated >100%underestimated >100%

For cancer screening, racial disparity For cancer screening, racial disparity among low SES underestimated the mostamong low SES underestimated the most

ConclusionsConclusions

Standard Medicare coding of Standard Medicare coding of race/ethnicity is unreliablerace/ethnicity is unreliable

Medicare coding can be enrichedMedicare coding can be enriched Enrichment is important to correctEnrichment is important to correct

– Wrong direction of disparity among AsiansWrong direction of disparity among Asians

– Large underestimates of disparities among Large underestimates of disparities among Blacks, Hispanics, AI/ANBlacks, Hispanics, AI/AN Especially those of low SESEspecially those of low SES

CMS does use enriched coding for some CMS does use enriched coding for some analyses, but does not do so routinelyanalyses, but does not do so routinely