Medicare Race/ethnicity Data

1. Medicare Race/ethnicity Data Academy Health 2005 Annual Meeting Boston A. Marshall McBean, M.D., MSc.

2. Medicare and Its Friends:SSA and RRB • Medicare race/ethnicity information in the Medicare Administrative data is NOT collected by Medicare • Race/ethnicity information comes from either the Social Security Administration or the Railroad Retirement Board • Don’t shoot the messenger (please)

3. Behind the Scene at SSAA – The Forms • From the beginning – 1936 – SS-5 Form • One variable • Three categories: White, Black, Other • 1980 – SS-5 form, “Other” replaced with: • Hispanic • Asian, Asian American, Pacific Islander • North American Indian or Alaskan Native

4. Behind the Scenes at SSAB – The Files • SS-5 form race/ethnicity information placed in 4 files at SSA: • MEF (Master Earnings File) • MBR (Master Beneficiary Record) • SSR (Supplemental Security Record) - SSI • NUMIDENT – Numerical Identification file, created between 1973 and 1979 as a new computer file containing the SS-5 information. One record for every SSN ever issued. But, 20% (80 million records) of race/ethnicity information lost during the transfer to electronic format. (Note: Information is still in the MBR for those who were receiving benefits at that time, but not in NUMIDENT.) 1980 NUMIDENT modified to include all 6 race/ethnicity codes. But the form and the file had only the one-item race/ethnicity variable.

5. Race/ethnicity Data Stored at SSA • MBR • SROP – Sex and Race of the Primary (SROP) • The original 3 race categories, plus Unknown. • NUMIDENT • 1973-1979 – Race information of the beneficiary; the original 3 race categories, plus Unknown • 1980 to present – Race information in 6 categories, plus Unknown

6. Transfer of SSA Information to CMS: Daily and “Annually” • MBR • File information transferred daily • What race information? • NUMIDENT • 1994, 1997 and annually” since 2000

7. Behind the Scenes at the Railroad Retirement Board (RRB) • The RRB does NOT collect information on race/ethnicity • Therefore, many Medicare records with “Unknown” are RRB beneficiaries

8. Medicare’s Reaction to the Race Variable • Passive • 1966 through 1993 • one variable • 3 + 1 race categories • 1994 through present • one variable • 6 +1 race/ethnicity categories

9. Medicare’s Reaction to the Race Variable • Active • 1997 – Survey of beneficiaries with race category Other or Unknown or living in certain areas. 2.2 million sent out. 800k returned. • 1997, 2000 and annually since then – updates with the NUMIDENT file information • 1999 and quarterly since then – Demographic Information from Indian Health Service on IHS users matched to EDB • RESULTS

12. How Good is the Information? • Compared with expected (U.S. Census data) -- 1993 and 1997 • Compared with self-reported race/ethnicity -- Validity of administrative data compared with self-reported race/ethnicity found it the Medicare Current Beneficiary Survey (MCBS) – 1997 and later

16. Number of Medicare Beneficiaries by Race/ethnicity Group, 1994 and 1997, from Medicare Denominator File for that Year

18. Validity of Administrative Data:Comparison with MCBS • Sensitivity – The proportion of true (self-reported) positives that are found – The proportion of self-identified Hispanics who are identified in Medicare data as Hispanics • Specificity – The proportion of true (self-reported) negatives who are found – The proportion of persons who are self-identified as NOT Hispanic who are identified in Medicare data as NOT Hispanic. • Positive predictive value (PPV) – The proportion of persons identified as Hispanic in the administrative data who are truly Hispanic (self-report as Hispanic)

19. Validity of EDB Race/Ethnicity Classifications Compared with MCBS, 1997 (n=15,168) (Arday et al, 2000)

20. Number of Medicare Beneficiaries in Medicare Denominator file by Race/ethnicity in 1997 and 2001 and Percent Increase

21. Validity of EDB Race/Ethnicity Classifications Compared with MCBS, 2002

22. Validity of EDB Race/Ethnicity Classifications Compared with MCBS, 1997 compared with 2002

23. Race of the Dependent Person The race coded in the EDB and Denominator files is the race of the person under whom benefits are claimed, the wage earner. The variable is the SROP, sex and race of the primary). (Approximately 79% of the elderly claim benefits based on their own earnings.) The race of the dependent spouse, widow or child closely corresponds to the race of the primary claimant.

24. Comparison of validity of race/ethnicity information of wage earner (BIC = A) with dependent person (BIC not = A) using 1997 MCBS and Denominator file

25. Color Coded Ideas, Suggestions and Recommendations • Have SSA replace or update the SS-5 form • Survey the Medicare population and gather self-reported ethnicity and race • Replace the SROP variable • Provide NUMIDENT information every day, week or month • Change the voluntary nature of race/ethnicity reporting

26. Ideas, Suggestions and Recommendations • Supplement the Medicare Enrollment Database with variables from other sources (MBD –Master Beneficiary Database): • CMS Surveys • CAHPS and FFS-CAHPS • Health of Seniors (HOS) • Medicare Advantage plans • Indian Health Service • Use of Hispanic or Asian surname to identify Hispanics and Asians

27. Accuracy of EDB Race/Ethnicity Classifications Compared with MCBS, 1997 (n=15,168) (Arday et al, 2000)