Medicare Race/ethnicity Data

Academy Health2005 Annual Meeting

BostonA. Marshall McBean, M.D., MSc.

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)

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

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.

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

Transfer of SSA Information to CMS: Daily and “Annually”

• MBR – File information transferred daily– What race information?

• NUMIDENT– 1994, 1997 and annually” since 2000

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

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

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

Number of Asian, Hispanic and North American Natives in Medicare Program, 1993-2003

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

UnknownOtherAsianHispanicNorth American Native

100% Medicare Enrollees 2003, by Race/ethnicity (Source = EDB)

84.2%

9.8%

2.3%

1.4%

0.4%

0.2%

1.6%

White 84.2%

Black 9.8%

Hispanic 2.3%

Asian 1.4%

NAN 0.4%

Other 1.6%

Unknown 0.2%

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

Number of Medicare Beneficiaries by Race/ethnicity Group, 1994 and 1997,

from Medicare Denominator File for that Year

Race group1994 1997 Percent

increaseBlack 2,577,377 2,753,251 6.8Asian 117,515 398,510 339.1Hispanic 228,198 700,462 307.0No. American Native 20,733 40,107 193.4

Number of Beneficiaries

Percent of Elderly Medicare Beneficiaires Enrolled in Medicare Compared with U.S. Census Bureau

Estimates, 1997

9489

30

44

23

0

10

20

30

40

50

60

70

80

90

100

White Black Hispanic Asian Native Am.

Perc

en

t

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)

Validity of EDB Race/Ethnicity Classifications Compared with MCBS,

1997 (n=15,168) (Arday et al, 2000)

Race Sensitivity Specificity PPV% % %

White 97 89 98Black 95 100 96Hispanic 39 100 98Asian/P.I. 58 100 79N. Am. Nat. 11 100 78Other 8 99 10

Number of Medicare Beneficiaries in Medicare Denominator file by Race/ethnicity in 1997 and

2001 and Percent Increase

Race group Number of Medicare Beneficiaries1997 2001 Percent

increaseBlack 2,753,251 3,994,854 31.1Asian 398,510 601,332 33.7Hispanic 700,462 951,019 26.3No. American Native 40,107 71,157 43.6

Validity of EDB Race/Ethnicity Classifications Compared with

MCBS, 2002

Race Sensitivity Specificity PPV% % %

White 97 90 98Black 97 100 97Hispanic 33 100 95Asian/P.I. 52 100 83No. Am. Native 33 100 92Other 7 100 9

Validity of EDB Race/Ethnicity Classifications Compared with

MCBS, 1997 compared with 2002

Race Sensitivity Specificity PPV% % %

White 97 97 89 90 98 98Black 95 97 100 100 96 97Hispanic 39 33 100 100 98 95Asian/P.I. 58 52 100 100 79 83No. Am. Native 11 33 100 100 78 92Other 8 7 99 100 9 10

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.

Comparison of validity of race/ethnicity information of wage earner (BIC = A) with

dependent person (BIC not = A) using 1997 MCBS and Denominator file

Race Sensitivity PPV

BIC = A

BIC not = A

BIC = A

BIC not = A

White 99 99 96 95

Black 97 95 94 97

Hispanic 43 40 98 98

Asian 46 71 63 79

N. Am. N. 15 10 71 67

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

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

Accuracy of EDB Race/Ethnicity Classifications Compared with MCBS,

1997 (n=15,168) (Arday et al, 2000)

Race Sensitivity Specificity PPV Kappa% % %

White 97 89 98 0.82Black 95 100 96 0.95Hispanic 39 100 98 0.54Asian/P.I. 58 100 79 0.66N. Am. Nat. 11 100 78 0.19Other 8 99 10 0.08