SupportingStatementPartB

Supporting Statement – Part B
Collections of Information Employing Statistical Methods

1. The target universe is current Medicare beneficiaries entitled to hospital and/or supplementary
medical insurance, living in the 50 states, the District of Columbia, and Puerto Rico. Both
institutionalized and non-institutional beneficiaries are represented. Table B.1 summarizes the
number of beneficiaries in the target universe based on CMS administrative records for the past
six years. The seven age groups shown in the table correspond to sampling strata from which the
samples for the MCBS are drawn. The age groups are defined by the beneficiaries’ age as of July
1 of the given year.
Table B.1: Universe Counts Broken Down by MCBS Sampling Strata
─────────────────────────────────────────────────────────────────────────────
Age
2005
2006
2007
2008
2009
2010
Interval
(est.)
(est.)
(in thousands)
Disabled
0 - 44
1,714.8
1,710.4
1,734.8
1,748.7
1,755.6
1,762.7
45 - 64
4,885.1
5,165.6
5,372.7
5,604.7
5,720.7
5,839.1
Total
6,599.9
6,876.0
7,107.4
7,353.4
7,476.4
7,601.4
Aged
65 - 69
70 - 74
75 - 79
80 - 84
85+
Total

9,209.1
8,382.3
7,334.5
5,602.8
5,064.5
35,593.3

9,498.4
8,451.6
7,280.4
5,608.7
5,225.5
36,094.6

9,826.8
8,578.8
7,220.2
5,677.6
5,430.7
36,734.1

10,430.5
8,805.3
7,156.3
5,700.6
5,574.1
37,666.7

10,732.4
8,918.5
7,124.3
5,712.0
5,645.8
38,133.0

11,043.0
9,033.2
7,092.5
5,723.5
5,718.4
38,605.1

Total
42,193.2
42,970.6
43,841.6
45,020.1
45,609.4
46,206.5
─────────────────────────────────────────────────────────────────────────────
Source: Historical counts (2005-08) are based on CMS administrative records. Projections (2009-10) from the
historical counts are based on the average annual rate of change from 2007-08. Distributions by age
interval are estimated. Totals do not necessarily equal the sum of rounded components.

The target sample size of the MCBS is designed to yield 12,000 completed cases a year
(approximately 1,000 disabled enrollees under the age of 65 in each of two age strata, and 2,000
enrollees in each of 5 age strata for enrollees 65 or older). To achieve the desired number of
completed cases, the MCBS selects new sample persons each year to compensate for nonresponse, attrition, and retirement of sample people in the oldest panel, and to include the newly
eligible population, while continuing to interview the non-retired portion of the continuing sample.
The MCBS usually adds approximately 6,450 – 6,600 beneficiaries to the sample in the September
- December round each year to replace the existing panel and to offset sample losses due to nonresponse and attrition. However, this number can be lower or higher depending on available
resources and the extent of non-response in the previous rounds. Approximately 4,000 sample
1

persons in the oldest panel are retired from the study in the May - August round each year, but this
number varies from year to year. As a result, the sample size averages approximately 16,500
interviews per round, which yield approximately 12,000 cases with completed annual utilization
and expenditure information.
Sample persons who refuse one or more rounds or who cannot be located for one of the scheduled
interviews are not counted as completed cases. Proxy interviews are attempted for deceased
sample persons. If data are collected through the date of death, then such cases are counted as
completes. For sample persons who reside in both a community and a facility setting, the round is
considered complete, if community and facility interviews are completed.
Sample persons remain in the survey when they are unavailable for an interview in a given round;
that is they are carried forward into the next round. For these individuals the reference period for
their next core interview covers the period since their last interview, so that there will not be a gap
in coverage of utilization and expenditure data. Supplements are administered for the current
round only. If a sample person is unavailable for two rounds in a row, they are not scheduled for
any further follow-up because extension of the recall period beyond eight months is not feasible.
A broad range of statistics is produced from the MCBS. Robustness and generality have been
stressed in sample design rather than customizing for specific goals. We anticipate that we will
continue to over-sample the extreme elderly and the disabled. The methodology for drawing the
samples is described later in this document. The number of cases to be selected each year
(designated sample sizes) are larger than targeted completes to compensate for initial non-response
and ineligibility. To see an illustration of the extent of the compensation necessary in Round 55 to
achieve the desired number of cases providing annual data, see Table B.2. We anticipate that
roughly the same or larger numbers will need to be selected in Rounds 58, 61, and 64.
Table B.2: Sample Size Needed to Compensate for Initial NonResponse and Ineligibility
Desired average
number of cases
Number
Age on
providing
sampled
July 1 of
annual data
at Round 55
of reference year
─────────────────────────────────────────
0-44
333
615
45-64
333
550
65-69
667
1,450
70-74
667
880
75-79
667
1,135
80-84
667
1,160
85+
667
1,125
Total

4,001

6,915
2

Cross-sectional sample sizes for other domains. There are multiple domains of interest in the
MCBS, for example, respondents with end-stage renal disease, persons residing in nursing
homes), managed care enrollees, beneficiaries of various race and ethnic backgrounds, and
Medicaid recipients. The MCBS will continue to maintain a minimum target of 12,000 completed
responses annually to help ensure that analysis can be performed on MCBS data for many
domains of interest.
Sample sizes for longitudinal analyses. Under the rotating panel design specified for the MCBS,
respondents remain in the sample for up to twelve rounds of data collection over a four year time
period. The historical response rates and attrition rates observed in the MCBS are used to
determine the rotational sample size and configuration of each new incoming panel. The
rotational sample design attempts to achieve consistency in subgroup sample sizes across all
panels comprising a particular calendar year.
Table B.3 presents the round-by-round conditional and cumulative response rates as of Round 52
(fall round of 2008) for the samples (referred to in the table as “panels”) selected in 2001 through
2008. For example, from the bottom part of the table, it can be seen that by the 10th round of data
collection for the 2005 panel, 60.4 percent of the 2005 panel were still in a formal responding
status (that is, either the SP was alive and still participating in the study or had died but left behind
a cooperative proxy for the collection of data on the last months of life) or had participated in the
survey until death, leaving enough data to estimate the last months of life. For the 2006 and 2007
panels, the corresponding cumulative response rates as of Round 52 were 63.5 and 64.1 percent,
respectively. The 2008 panel (the new panel selected in Round 52) ) had an initial response rate of
78 percent in its first round of data collection.
Round 52 (fall, 2008) is the latest round for which MCBS data have been processed. There were
3,133 interviews successfully completed at Round 52 with still-living members of the 2005 panel.
For brevity, we refer to these 3,133 interviews as “live completes”. For the 2006 and 2007 panels
there were 3,562 and 3,801 live Round 52 completes, respectively. For the first round of data
collection for the 2008 panel, there were 4,053 completes at Round 52.
The MCBS has used a variety of techniques to maintain respondents in the survey and reduce
attrition. These will be continued and adapted to comply with the time frames for initiating and
implementing the continuous sample.
2. This section describes the procedures used to select the samples for the national survey. It
includes a general discussion of the statistical methodology for stratification and rotational panel
selection, estimation procedures, and the degree of accuracy needed. This is followed by a
presentation of how topical supplements are used to enhance the analytic potential of the MCBS
data. The content of the continuous or core questionnaires is then summarized. Finally, there is a
discussion of rules for allowing proxy response.
a. Statistical methodology for stratification and sample selection. This section opens with a
description of the MCBS sample design. This is followed by a general discussion of the
selection of the original and supplemental samples, and the use of different five percent
3

HISKEW samples each year to reduce problems associated with duplication of samples
across the years.
Table B.3: Conditional Response Rates as of Round 52 for Medicare Current Beneficiary Survey by
Interview Round

Round 1
Round 2
Round 3
Round 4
Round 5
Round 6
Round 7
Round 8
Round 9
Round 10
Round 11
Round 12

2001 Panel
(n = 6302)

2002 Panel
(n = 6301)

2003 Panel
(n = 6300)

2004 Panel
(n = 6342)

2005 Panel
(n = 6565)

2006 Panel
(n = 6675)

2007 Panel
(n = 6680)

2008 Panel
(n = 5532)

84.8%
93.1%
96.1%
96.1%
97.1%
97.9%
98.1%
98.1%
98.6%
98.0%
99.0%
99.8%

84.3%
92.9%
96.6%
96.9%
97.8%
97.9%
97.1%
98.3%
98.5%
98.7%
99.2%
99.8%

83.2%
92.9%
95.5%
96.1%
97.8%
97.7%
98.3%
98.1%
98.8%
99.0%
99.3%
99.9%

82.2%
92.8%
95.9%
96.6%
97.4%
98.3%
98.0%
98.2%
98.7%
98.5%
98.6%
99.8%

82.0%
91.6%
96.0%
96.3%
97.1%
97.7%
97.7%
98.2%
97.3%
98.3%

82.8%
92.0%
95.5%
95.7%
96.6%
96.8%
97.7%

80.3%
90.3%
93.5%
94.7%

78.0%

Cumulative Response Rates for Medicare Current Beneficiary Survey by Interview Round

Round 1
Round 2
Round 3
Round 4
Round 5
Round 6
Round 7
Round 8
Round 9
Round 10
Round 11
Round 12

2001 Panel

2002 Panel

2003 Panel

2004 Panel

2005 Panel

2006 Panel

2007 Panel

2008 Panel

(n = 6302)

(n = 6301)

(n = 6300)

(n = 6342)

(n = 6565)

(n = 6675)

(n = 6680)

(n = 5532)

84.8%
79.0%
75.9%
72.9%
70.8%
69.3%
68.0%
66.7%
65.8%
64.5%
63.8%
63.7%

84.3%
78.3%
75.6%
73.3%
71.6%
70.1%
68.0%
66.9%
65.9%
65.0%
64.5%
64.3%

83.2%
77.3%
73.9%
71.0%
69.4%
67.8%
66.6%
65.4%
64.6%
63.9%
63.4%
63.4%

82.2%
76.3%
73.2%
70.7%
68.8%
67.7%
66.3%
65.2%
64.3%
63.3%
62.5%
62.3%

82.0%
75.1%
72.1%
69.5%
67.5%
65.9%
64.4%
63.2%
61.5%
60.4%

82.8%
76.2%
72.8%
69.6%
67.2%
65.1%
63.5%

80.3%
72.5%
67.7%
64.1%

78.0%

1) The MCBS employs a complex multistage probability sample design. At the first stage of
selection, the sample consists of 107 primary sampling units (PSUs) defined to be
metropolitan areas and clusters of non-metropolitan counties. At the second stage of
selection, samples of ZIP code areas (5 digit) referred to as ZIP fragments are selected
within the sampled PSUs. Prior to the Fall data collection round, new ZIP fragments are
sampled within the PSUs each year to give recently created ZIP codes appropriate
representation in the sample. At the third and final stage of selection, stratified samples of
4

beneficiaries within the selected ZIP fragments are sampled at rates that depend on age
group.

PSU and ZIP code clustering. The MCBS is in the final phase of implementing its first
PSU redesign. The original MCBS PSU sample was selected in 1991 and consisted of 107
primary sampling units (PSUs) defined to be either metropolitan areas or groups of nonmetropolitan counties. Within the PSUs, the initial sample of second-stage units consisted
of 1,163 clusters of ZIP code areas (5 digits). This number increased to about 1,500 ZIP
clusters by 2000 as new ZIP codes were added to the sample. .
As a result of the unequal growth of the Medicare population across different areas of the
country, the workload distribution across the sampled PSUs became less efficient over time.
Moreover, there was evidence that design effects (which reduce sampling precision) had
also increased. For this reason, in 1999, CMS and Westat staff began an evaluation of the
existing PSU structure. Following the analysis of the aging PSU structure, a decision was
made to reselect the PSUs. Attachment 10 is the evaluation of alternative measures of size
for PSU selection that led to this decision. The new PSUs were phased in over a four-year
period in conjunction with the drawing of each new panel. The reselection of the PSUs did
not involve increases in respondent sample size, nor increases in respondent burden.
The 2001 panel was the first panel in which the redesigned PSUs were used. Like the
original sample, 107 PSUs were selected of which 63 were retained from the original
sample. With the rotating panel design, the PSU redesign has been transparent to data users
and no special processing has been required. The strata used for selection of the PSUs
cover the 50 states, the District of Columbia and Puerto Rico. There are some states
without any sample PSUs within their boundaries. Within major strata defined by region
and metropolitan status, substrata defined to be internally homogeneous with respect to
socio-economic data from the 1990 Census were created for sample selection. The sample
PSUs are listed in Attachment 11.
Within the PSUs, an initial sample of 1,209 second-stage units consisting of clusters of ZIP
code areas was selected. All of the ZIP cluster samples were selected from CMS's master
file of beneficiaries enrolled in Medicare, using the beneficiary's address recorded in that
file as of March of the year the individual was selected for the sample There were several
steps in this sampling process. The first was to form ZIP fragments (the intersections of
ZIP code areas and counties in sample PSUs). The second was to assign a measure of size
to each ZIP fragment. The measure of size was closely related to the total count of
Medicare beneficiaries residing in the ZIP fragment, but beneficiaries in domains to be
over-sampled (such as persons over age 84) were counted more heavily than persons to be
under-sampled (such as persons aged 66 to 69). Some of the ZIP fragments had very small
numbers of beneficiaries residing in them. These small ZIP fragments were collapsed with
other ZIP fragments until the aggregate measure of size for each cluster was large enough to
provide a reasonable cluster size for the sample. A sample of these ZIP clusters was then
selected with probability proportionate to the measure of size, using systematic sampling
5

with a random start.
2) Selection of beneficiaries. At the inception of the MCBS, an initial sample of over 15,000
beneficiaries was selected from the 5-percent sample of the Health Insurance Master File
(HIM), also referred to as a 5-percent HISKEW. This sample was clustered within the
selected PSUs and ZIP fragments and was designed to effect uniform sampling weights
within seven age domains at the national level. Beginning in Round 10, with the transition
to a rotating panel design, samples of approximately 6,450 beneficiaries (eligible on
January 1 of each year) have been selected from a 5-percent HISKEW each year. Nursing
home residents are drawn into the sample in exactly the same manner as other beneficiaries
residing in the community.
Each year, a new supplementary sample (referred to as a panel) is selected for the MCBS.
To determine the appropriate sample sizes for the new panel, the MCBS sample sizes
achieved in the prior year are reviewed in April of each year. New projections are made of
the sample size necessary to obtain the targeted number of responding cases in subsequent
cost-and-use data releases. For example, it was projected that roughly 6,900 sample
beneficiaries would be needed for the 2009 panel (the latest panel selected for the MCBS)
in order to meet sample size goals. This number is higher than for previous panels because
of decreasing response rates.
b. Estimation procedure. To date, sampling weights have been calculated for Rounds 1, 4,
7…49 and 52 in the Access to Care Series. Both cross-sectional and longitudinal weights
have been calculated. These weights reflect differential probabilities of selection and were
adjusted for under-coverage and non-response. Replicate weights were also calculated so
that users can calculate standard errors using replication methods. In addition to the
replicate weights, stratum and unit codes exist on each weight file for users who prefer to
use Taylor Series methods to estimate variances.
Besides standard weighting and replicate weighting, another part of the estimation program
includes the full imputation of the data sets to compensate for item non-response
(Attachment 9). Imputation of charges for non-covered services and sources of payment for
covered services in the Cost and Use annual file have been developed. The weighting and
imputation of data will continue.
c. Degree of accuracy needed for the purpose described in the justification. A broad range of
statistics will be produced from the MCBS. There is no single attribute of beneficiaries and
their medical expenses that stands out as the primary goal of the survey. Thus, there can be
no simple criterion for the degree of reliability that statistics for each analytic domain
should satisfy. Even with a minimum of 15,500 sample persons, there will be many small
domains of interest for which it will be necessary to use modeling techniques or to wait
several years for sufficient data to accumulate. Examples include people with specific
medical conditions (e.g., hip fractures), institutionalized persons under age 65, Hispanic
persons, and sample persons experiencing spend down.
6

The MCBS will maintain a stratified approach to the selection of the sample. The sample
will continue to be clustered by PSU and ZIP Code and stratified by age domain. We
anticipate maintaining a total of 2,000 annual cases allocated to the disabled. The two age
categories were selected because they indirectly reflect the means by which the disabled
person becomes eligible for Medicare. Since the number of disabled sample persons per
PSU and ZIP code will be small, the effects of clustering on statistical precision should be
mild. It is anticipated that post-stratification by characteristics in CMS databases will more
than compensate for the effects of clustering. Thus, with an effective sample size of 1,000
or more for each age stratum, accuracy for each of the two age strata should not be much
different from that commonly attained in public opinion surveys. Since many of the
statistics may be heavily right-skewed, the accuracy may be lower in relative terms but still
acceptable.
Each of the age strata for the aged Medicare sample will be allocated 2,000 cases. A major
reason for over sampling the very old is to obtain an adequate sample of nursing home
stays, while minimizing design effects. Variations in sampling weights across the age strata
and clustering should result in an effective sample size of approximately 1000 cases
annually per stratum.
d. Interview content for periodic data collection cycles to reduce burden.
1) Content and timing of the continuous or core interview. The primary variables of
interest for the MCBS are the use and cost of medical care services and associated
sources and amounts of payment. While Medicare claims files supply information on
billed amounts and Medicare payments for covered services, the survey provides
information on use of services not covered by Medicare and on payment sources and
amounts for costs not reimbursed by Medicare. For both the household and facility core
components, the primary focus of the data collection is on use of services (dental,
hospital, physician, medical providers, prescription medication and other medical
services), sources and amounts of payment, and health insurance coverage. The “core”
MCBS interview collects continuous information on these items through thrice-yearly
interviews. The community component also contains summary components, which
update the household enumeration and health insurance status and follow-up on cost and
sources of payment information for “open items” from the previous interview.
Continuous data on utilization and expenditures are required for a number of reasons.
First, several of the distinct expenditure categories involve relatively rare medical
events (inpatient hospital stays, use of home health care, purchase of durable medical
equipment), so limiting the reference period would mean insufficient observations for
national estimates. Second, episodes of medical care often consist of a series of services
over weeks or months; continuous data will allow examination of the grouping of
services around particular episodes of care. This is particularly important when a
number of medical services are included in a global fee. Third, payment for medical
services often occurs considerably later than the utilization, so collection of complete
7

information about a particular event can often only be obtained some time after the
event occurs. In addition, this emphasis on utilization and expenditures will formulate
an excellent baseline to monitor both Medicare reform and CMS’ program management
effectiveness.
The administration of the instruments will continue to follow the established pattern of
data collection, i.e., baseline information will be collected in the initial interview. This
will be followed in all subsequent interviews with the core component. The core
community and facility components are administered in the second interview (January
through April) to maintain a consistent reporting period for utilization and expenditure
data. Since the initial interview always occurs in the last four months of a calendar
year, collection of utilization and expenditure data in the second interview means the
reference period will always begin prior to January 1st. This creates use and
expenditure estimates on a calendar year basis.
The access, enumeration and demographic series (i.e., baseline information) will be
asked and reference dates established in Rounds 58, 61 and 64 for those individuals new
to the MCBS. The core components are administered in every round thereafter. For
those continuing sample persons, we administer the core questionnaire in addition to the
baseline instrument in Rounds 58, 61 and 64.
The literature (initially reported by Neter and Waksberg in 1964, and confirmed in
subsequent research by other analysts) indicates that collection of behavioral
information in an unbounded recall period can result in large recall errors. A part of the
initial interview (Rounds 58, 61 and 64) prepares the respondent for the collection of
utilization and expenditure information in subsequent rounds, thus “bounding” the recall
period for the next interview. In addition, at the conclusion of the initial interview, the
sample person (new rotational sample only) is provided with a calendar. This calendar
marks the recall period for the respondent, serves as the means to record utilization, and
as a prompt to retain statements and bills.
2) Content of the core/continuous questionnaire, Rounds 58-66. We are proposing no
change in content in the core questionnaire for Rounds 58-66.
Community Questionnaire.
Introduction and enumeration section. In the initial interview, the MCBS collects
information on the household composition, including descriptive data on the household
members such as age, gender and relationship to the sample person. We also verify the
address and telephone number of the sample person. This information is updated in
each subsequent round.
Health insurance. In the initial interview, we collected information on all sources of
secondary health insurance, both public and private, which cover the sample person.
Included are questions about premium, coverage, primary insured, source of the policy
8

(i.e., private purchase, employer sponsored, etc.) and managed care status. This
information is updated in each subsequent round.
Utilization series. This section collects information on the sample person's use of
medical services. We specifically probe for use of: dental services, emergency room
services, in-patient hospital services, outpatient hospital services, institutional services
(skilled nursing home services, intermediate care facility services, etc), home health
services, medical provider services (medical doctors, chiropractors, physical therapist,
etc.), prescribed medicines and other medical services. For each type of service
reported, we collect information on the source of care, type of provider, date that the
service was provided, and if medications were prescribed as a part of the event. This
episodic information is collected for all services since the date of the last interview.
Charge questions: statement and no statement series. These sections collect information
on costs, charges, reimbursements and sources of payment for the health care services
reported in the utilization series. If a respondent has an insurance statement (Medicare
Summary Notice or private health insurance statement) for a reported medical service,
then the statement series is administered. For reported medical utilization, if a
respondent indicates that a statement has not been received, but they expect to receive a
statement, we defer asking about this service until the statement is received. If the
respondent doesn't have and doesn't expect to receive a statement, the no-statement
series is asked. Questions are asked about the cost of the services, charges, expected
reimbursement, and potential or actual sources of payment (including other family
members).
Summary Information. Updates and corrections are collected through the summaries.
For the enumeration, insurance and utilization sections, the respondent is handed a hard
copy of the information reported or updated in the previous round. The respondent is
asked to review this and make any corrections or modifications. For medical events, the
respondent is handed a hardcopy of the calendar. This replicates the reporting by month
from the previous round and reinforces utilizing a calendar for reporting events. These
summary sheets are prepared monthly so that the respondent can rapidly scan the
reported events and modify, add or delete episodes of health care. In addition, updates
to prescribed medication use can be made at this time.
In addition, information for events that remain open in the previous round (i.e., the
respondent expects to receive a statement, but had not received a statement at the time
of the last interview), is collected in the charge and payment summary. Information is
collected through this summary in a manner that is consistent with the statement or nostatement series.

9

Facility Questionnaire.
The facility component collects information that is similar in content to the household
interview. Sections of the institutional instrument parallel the household instrument,
i.e., residence history parallels the household enumeration section. The provider probes
capture information that is similar to the community utilization section and the
institutional charge series parallels the household charge series (statement and no
statement series). Differences in the facilities and community components result from
differences in the setting of the interview and the types of respondents. The facility
questionnaire is administered by the interviewer to one or more proxy respondents
designated by the facility director. The household instrument is administered to the
sample person or their designated proxy. Both the household and facility interviews are
record driven. However, the facility respondents refer to formal medical care records,
while in the household, the respondent is dependent their own record keeping. The core
facilities instrument contains the following sections:
Residence History. This section collects continuous information on the residence status
of the sample person, including current residence status, discharge and readmission.
Health Services. This section collects information on medical use by type of service.
Type of providers and setting used are identified for reported medical events. In
addition information is collected on the number of times or volume of care received.
Prescribed Medicines. All medications administered in a facility are prescribed.
Information is collected on the name, form, strength, and dispensing frequency of the
medication.
Inpatient Hospital Stays. Information is collected on any inpatient hospital stays
reported in the Residence History.
Institutional charges. This section collects information from the institutions on the
charges, reimbursement levels and sources of payment for the sample person.
Information on bad debt and other sources of differences between bills and payments.
3) Content of topical supplements. The MCBS interview consists of core items and one or
more topical supplements. The content of the supplements is determined by the
research needs of CMS, the Department, and other interested agencies, including the
Medicare Payment Advisory Commission. Topics for the community component
include: income, assets, program knowledge and participation, demographic
information, health and functional status, satisfaction with care, and usual source of
care. For the facility instrument topical supplements include the eligibility screener and
the baseline instrument (contains questions on demographics and income, residential
history, health status and functioning, type of housing and health insurance).

10

For the community interview we are requesting clearance to continue to field the
Overlap series (i.e. Usual Source of Care, Access to Care, Satisfaction with Care, Health
Status and Functioning, Health Insurance, Household Enumeration, Housing
Characteristics, Demographics and Income, and Provider Probes), Income and Assets,
Table B.4: Supplements for Clearance
2010
Round 58
Core interview
Overlap Series
Facility: Baseline and Screener
2011
Round 59
Core Interview
Knowledge and Information Needs
Drug Coverage
Facility: Baseline and Screener

Round 60
Core Interview
Income and Assets
Patient Activation

Round 61
Core Interview
Overlap Series
Facility: Baseline and Screener

2012
Round 62
Core Interview
Knowledge and Information Needs
Drug Coverage
Facility: Baseline and Screener

Round 63
Core Interview
Income and Assets
Patient Activation

Round 64
Core Interview
Overlap Series
Facility: Baseline and Screener

2013
Round 65
Round 66
Core Interview
Core Interview
Knowledge and Information Needs
Income and Assets
Prescription Drug Choice
Prescription Drug Awareness
Drug Coverage
Patient Activation
──────────────────────────────────────────────────────────────

- Household Core Interview = Household Composition, Health Insurance, and Utilization and Charge Series (statement/nostatement series)

- Facility Core Interview = Residence History, Provider Probes, Prescription Medications, Hospital Stay and Institutional Charges.
- Overlap Series =Access to Care, Satisfaction with Care, Usual Source of Care, Health Status and Functioning, Housing
Characteristics, Demographics and Income.
- Facility Baseline = Demographics and Income, Residence History, Health Status and Functioning, and Health Insurance.

Knowledge and Information Needs, Prescription Drug (to complement the change in the
enrollment period, content will be split between Jan – Apr and May – Aug rounds), and
Patient Activation supplements. For the facility interview, we are requesting clearance
for the eligibility screener and the baseline instrument.
Table B.4 presents the supplements that we are seeking clearance for at this time. If
additional supplements are planned, separate clearance packages will be developed.

11

e. Rounds 58 through 66 data collection procedures.
1) Interviews with sample persons in community. In Round 58, 61 and 64 all newly
selected sample persons will be sent an advance letter (Attachment 3) from the Centers
for Medicare and Medicaid Services. Interviewers will carry copies of the advance
letter for sample persons who do not recall receiving one in the mail, as well as a copy
of the MCBS brochure and question-and-answer sheet (Attachment 3). This process
was and will continue to remain effective.
The household component interview (Rounds 58-66) will be administered to the sample
person or a proxy using a computer-assisted personal interviewing (CAPI) program on a
laptop computer. A hard-copy representation of the continuous core for Rounds 58-66
CAPI interview for persons living in the community is shown in Attachment 4.
Attachment 4 includes a copy of the instrument that is administered in the initial
interview, the ongoing interview, and the Show Cards, used by the interviewer to assist
in the interviewing process.
At the completion of the initial interview i.e., Rounds 58, 61 and 64 interview, each new
sample person is given a MCBS calendar, on which he or she is encouraged to record
health care events. The same calendar is provided to all continuous community
respondents on a calendar year basis.
2) Interviews with sample persons in institutions. All new facility admissions during
Rounds 48-57, will be traced to the institution where they reside. For the initial facility
interview the Eligibility Screener, Baseline and Core Questionnaires are administered.
All facility interviews are administered to facility staff using a CAPI program on a
laptop computer. For all facility residents, the facility screener is administered during
the Fall of each year (Attachment 5). The facility core institutional questionnaire to be
used in Rounds 58-66 is shown in Attachment 6.
Some administrators will require consent of the sample person or a next of kin before
releasing any information. The data collection contractor will offer to obtain such
written consent, using the consent form and letter included as Attachment 7.
3) Verification Interviews. A brief verification re-interview (Attachment 8) will be
conducted for 10 percent of the interviews.
f. Proxy rules. For community sample persons, the preferred mode is self-response. During
the initial interview (with subsequent updates), sample persons are asked to designate proxy
respondents. These are individuals who are knowledgeable about the respondent’s health
care and costs and expenditures for this care. In the MCBS, only those individuals who are
designated by the sample persons can serve as proxy respondents.

12

The facility setting presents a different and changing set of circumstances for the MCBS. In
the past the MCBS used the policy of making no attempt to directly interview residents in a
facility. But, changes in elderly care have interviewers encountering facilities, which
provide a wider range of services that fall outside the scope of traditional Medicare certified
facilities. In some cases, such as custodial care and assisted living communities, the best
person for answering our questions is the beneficiary, rather than facility staff. MCBS
interviewers are now trained to determine and seek out the appropriate source for
interviewing. While we feel that the majority of facility interviews will continue being
conducted with facility staff, having no contact with the beneficiary, there will be cases for
self-response in the facility setting. For persons who move in and out of long-term care
facilities, standard procedures will be used to determine the best respondent to provide data
about the period spent outside of such facilities. Self-response will be used in prisons if
permitted. Other institutions will be treated on a case-by-case basis.
3. MCBS is sampling a heterogeneous population that presents a unique challenge for maximizing
response rates. The household survey will be approaching two groups--aged and disabled
Medicare beneficiaries—who have characteristics that often lead to refusals on surveys.
Increasing age, poor health or poor health of a family member are prevalent reasons for refusal.
On the other hand, older persons are the least mobile segment of the population and thus less
likely to be lost due to failure to locate. The disabled population tends to have a slightly higher
response rate than the aged population. While the percentage of non-response do to death is
comparable to that of the 70-74, 75-79 and 80-84 age brackets, refusal rates are the lowest of all
age categories.
Because this is a longitudinal survey it is essential that we maximize the response rates. In order
to do so, survey staff undertakes an extensive outreach effort annually. This includes the
notification of government entities (CMS regional offices and hotline, carriers and fiscal
intermediaries, and Social Security Offices), national organizations including the American
Association of Retired Persons, the Association for Retarded Citizens and various community
groups (e.g., mayor's offices, police, social service and health departments, home health agencies,
state advocates for the elderly and area agencies on aging). These efforts are undertaken to
increase the likelihood that respondents would answer the MCBS questions and remain in the
survey panel by: 1) informing authoritative sources to whom SPs are likely to turn if they suspect
the legitimacy of the MCBS; 2) giving interviewers resources to which they can refer to reassure
respondents of the legitimacy/importance of the survey; and 3) generally making information
about MCBS available through senior centers, other networks to which SPs are likely to belong
and through the CMS website.
In addition to the outreach efforts, the following efforts remain in place to maintain a sense of
validity and relevance among the survey participants.
a. An advance letter is sent to both potential sample persons and facility administrators from
CMS with the Administrator's signature. This includes an informational brochure
answering anticipated questions.
b. A handout with Privacy Act information and an appeal to participate is given to the SP at
13

c.
d.

e.
f.
g.
h.
i.
j.

k.
l.

the door by the interviewer.
Interviewer training emphasizes the difficulties in communicating with the older
population and ways to overcome these difficulties.
Individualized non-response letters are sent to SPs who refuse to participate. These letters
are used when deemed appropriate by the field management staff. CMS staff follows up
with respondents who refused because of concerns about privacy and federal sponsorship
of the survey.
Proxy respondents are sought for SPs unable to participate for themselves.
Non-respondents are re-contacted by a refusal conversion specialist.
A toll-free number is available at Westat to answer respondent's questions.
An E-mail address and website are available at CMS to answer respondent’s questions.
The sample person is paired with the same interviewer throughout the survey. This
maintains rapport and establishes continuity of process in the interview.
Periodic feedback mechanisms have been established. These include describing the
availability of data, types of publications presenting MCBS data and preliminary findings
presented in the form of data summaries.
We encourage personal touches, including interviewer notes and birthday cards.
Personal letters of appreciation have been sent from the Federal Project Officer. These
letters include information on recent publications from the MCBS and status of the project.
In addition, information on selected supplements (e.g., Income and Assets) has been
mailed to sample persons prior to the interview.

In contrast to most surveys, the MCBS has a large amount of information to characterize nonrespondents. This information, including Medicare claims data, can be used for imputation if
necessary. To minimize the risk of bias from non-response the most up-to-date non-response
adjustment techniques are used. Models predicting the propensity not to respond are built based
upon the extensive administrative databases available and upon data from earlier rounds. We then
use propensity to respond to form cells to adjust respondent weights. Simultaneously, the
substantive characteristics of non-respondents will continue to be tracked in the administrative
databases to monitor the risk of bias.
4. At this time there are no plans to conduct field testing of the currently established procedures
or methods. From time to time various parts of the questionnaire are modified or augmented to
reflect changes to the Medicare program, capture information on emerging areas of interest,
reduce unnecessary burden or to improve the quality of the data. If field testing becomes desirable
in the future, it will be submitted for approval separately or in combination with the next main
collection of information.

14

5. Person responsible for statistical aspects of design
Adam Chu
Senior Statistician
Westat, Inc.
(301) 251-4326
Westat, Inc., of Rockville, Maryland conducts the MCBS.

15