The Burden of Proo

Attrition and Record 

the Medicare Cu

Beneficiar

y Su

AAPOR A lC f nnua

l

Con

feren

Ryan Hubbard and Brad 
Outline

• MCBS & Record Usage• Research Questions• Analysis• Findings• Conclusions • Next steps
Record Usage and Perceived Respondent Burd

• Record use may increase or reduce perceiv

respondent burden.

• Any extra tasks which require respondent ef

be perceived as havin

g g a hi

gher total level o

regardless of the effect on total interview len

• Record kee

pg y p in

g ma

y be 

passive or active.

• Record usage may disproportionately affect 

subsam

ples.

• Respondents experiencing higher levels of p

burden will be more likel

y to dro

p out of the 

yp 
Bk d ac

kgroun

d
Medicare Current Beneficiary Survey

• Longitudinal Study for Centers for Medicare and Medicaid 

currently in Round 58

• 16,000 Medicare beneficiaries in a rotating panel design

• 12 round study including baseline and exit interview over • CAPI interview on health, health care utilization and healt

expendit d i d t t M di d i i t ti 

ditures 

designe

d

to augmen

t

M

edicare a

d

minis

trativ

events and payments

 Matches costs to health care events in an effort to enumerat

Matches costs to health care events in an effort to enumera

and payments.

 Relies on respondent collection and interviewer entry of med

insurance statements from multiple sources

 Asks respondents to voluntarily track health care utilization o

provided calendar.
Two Forms of MCBS Record Usage: Statements & 

• Respondents who collect and provide statements ar

only about amounts not accounted for by the statemmaterial.

• Respondents who fail to provide statements are ask

longer series of questions.

• During the baseline interview respondents receive a During the baseline interview, respondents receive

a

calendar to track medical events throughout the yea

• Res

p y ondents ma

y make use of their own calendars, 

appointment books, or check registers.

• Statement usage is passive, calendar usage is activ

are voluntary
Research Questions

• Does record usage increase attrition on the 

through increased perceived burden?

• Does the effect of statement collection diffe

calendar keeping?

• Are there other factors related to the interv

the resp g ondent that outweigh the effects of usage?
Analytical Approach

• Analysis uses the two most recently compl

panels in the study.

• Focus on the relative effect of record usag

non-death attrition in later rounds. 

• Excludes cases where attrition was due to 

or occurred prior to the second interview.

• Examine and control for other factors such 

average interview length, number of eventspercei d h lth th t t ib t t ived poor health that may contribute t

perceived burden.
Non-death Attrition from the MCBS

at

1639 of 6410 left the study 

661 left after 1st Round

triti

978 left after 2nd Round 

1 00 2 00 3 00 4 00 5 00 6 00 7 00 8 00 9 00 10 0 11 

ion

1 2 3 4 5 6 7 8 9 10 11 

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00 10.0 11.

Round

1

2

3

4

5

6

7

8

9 10 11 
Key Variables

Mean: 

analytic 

Variable sampleRefusal-based attrition (including physically/mentally no longer able) (including physically/mentally no longer able) .17

Ratio of rounds a calendar was used

.52 

Ratio of costs covered by a statement

.32 
Additional Predictors and Control Variables

Variable MeaEver use a proxy Age when entered study 

(1=0-44; 7=85+)

SP ever on Medicaid SP ever on Medicaid Any interviews conducte

Any interviews conducte

Average self-reported health (1=excellent; 5=poor)

MCBS panel (1=2008 exit

Married at some point during study Same interviewer througEligible for VA benefits Average interview length Highest degree (1=no school; 5=masters+) Average number of even

Household income < $25,000 Average health care pay

round ($) round ($)

Sex of sample person (1=male; 2=female) Average years of intervie

experience
Al d na

lyses an

d

Findings
Logistic Regression Models

Main Predictors Other Predictor Variables in ModelRatio of costs covered by statement

Average health care payments per round

Any interviews conducted in Spanish

Highobtai

R ti f d R

atio of roun

ds a SP MCBS l

E

calendar used 

SP ever on 

Medicaid

MCBS panel Eve

r 

Average 

i f

Same interviewer th h t t d

Hous

experience of < $25 

interviewer

throug

hout stu

d

y

< $25

Married at some Married at some Average interview Age point during study

Average interviewlength (min)

Age 

study 

Eli

gbe o i l f

or VA Av

e

rage n

u

mber 

of Sex 

o

benefits

e age u be o

events per round

Se o perso

Average of self reported health

(1=excellent;5=poor)
Logistic Regression Results: Key Predictors

N=5682Variable

Standardized 

Coeff [B]

Variable . [B] Ratio of costs covered by statement -2.01 

Ratio rounds calendar used 
Logistic Regression Results: Full Model

N=5193Variable

Standardized 

Coeff [B]

Variable . [B] Ratio of costs covered by statement -3.17 Ratio rounds calendar used -.39 Ever use a proxy -.47 

SP ever on Medicaid -.62 Avera

g p e of self re

ported health .11 

Eligible for VA benefits -.57 Age when entered study (categorical) .09 Any interviews conducted in Spanish Any interviews conducted in Spanish -.56 MCBS panel .27 Same interviewer throughout studyAverage interview length (min) -.02 

Average number of events per round .17 

Avera

ge 

years of interviewer ex

perience -.05 

g y

p
Summary of Results: Hypotheses Revisited

• Hi h l l f t t t d th lik lih 

Hi

g

her levels o

f s

t

a

temen

t usage re

duces the lik

eliho

refusal-based attrition. This relationship is stronger other in the model.

• Greater use of the calendar, controlling for other fact

reduces the likelihood for refusal-based attrition.

• A i t i ti Average in

terview time, average percei d h lth 

ive

d

health an

consistency of interviewer seem to have little or no eattrition propensity.

• Interviewer experience, VA eligibility, and Medicaid c

all show slight negative relationships with attrition.
Explanation of Findings

Two competing views:• Statement usage, because it is relatively p

and calendar usage, because it is voluntary may improve interview flow may actually dattrition through a reduction in perceived buattrition through

a reduction in perceived bu

• The effects we see actually represent unm

motivations such as topic salience and altrmotivations such as topic salience and altr

Those invested in the study are more likcom

py q l with re

quests for record kee

p g in

g 

complete all rounds of the study.
Conclusions

• The MCBS may be somewhat shielded fro

perceived record-keeping burden due its vonature the passive requirement for statemnature, the passive requirement for statem

and a baseline interview that requires no re

• Perceived burden may not translate into at

Perceived burden may not translate into at

it is offset by the perceived gain: either altran easier interview.

• Interview length may not equal increased 

p p erceived burden for the Medicare populat
Limitations and Next Steps

• The analysis would benefit from measures such a

saliency or respondent commitment to the study.

• The analysis lacks data regarding why the Sample The analysis lacks data regarding why the Sample

Person left the study. Plans to incorporate record calls/refusal information.

• Most non Most non

-death attrition occurs between the base

death attrition occurs between the base

interview and the first cost and use interview. A mcomplete examination should incorporate an analy

this early attrition this early attrition.
Ryan A. Hubba dr

RyanHubbard@westat.cBrad Edwards Brad EdwardsBradEdwards@westat.c