Nov 25 -- Centers for Medicare & Medicaid Services, Health and Human Services (HHS), invites comments to OMB by December 29, 2022 regarding a NORC study of the drivers of nonresponse to race and ethnicity questions by Medicare Parts C and D enrollees. [Note: Due date is 30 says after submission to OMB on November 29, 2022.]
As CMS moves towards stratified reporting of quality measures and addressing healthcare inequity, highlighted by the COVID-19 pandemic, the ability to analyze disparities across Medicare programs and policies depends on the ability to access and collect reliable race and ethnicity data consistently from Medicare Part C and Part D plans. The recent Executive Orders (E.O.) 13985 on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government and E.O. 14031 on Advancing Equity, Justice, and Opportunity for Asian Americans, Native Hawaiians, and Pacific Islanders, have focused attention on the need for CMS to improve the collection and quality of its enrollees' race and ethnicity data, especially at the disaggregated level.
Collecting complete race/ethnicity data is important to CMS because CMS has interest in identifying patterns of differences across many key process and care outcomes by sociodemographic characteristics, including race and ethnicity.
CMS' primary objective for the interviews is to identify the drivers of nonresponse to the race and ethnicity questions. Specifically, we aim to solicit detail on whether and what concerns drove individuals' nonresponse to these items, including (but not limited to) (a) concerns about confidentiality of their data, (b) concerns about how their race and ethnicity data would be used, including concerns about whether disclosing such information could in any way affect eligibility for Medicare benefits (which it would not), or (c) concerns about response options (e.g., missing response options for race or ethnicity groups in which they may identify). We also intend to explore whether it is possible to amend the race and ethnicity elements on Part C/D enrollment form to address any of those concerns, and if so, how. Additionally, we plan to ask whether there are other—beyond the Part C/D enrollment form—vehicles for collecting race and ethnicity information that would be more acceptable to non-responders, and if so, what those are.
Collecting complete race/ethnicity data is important to CMS because CMS has interest in identifying patterns of differences across many key process and care outcomes by sociodemographic characteristics, including race and ethnicity. To best characterize these differences, self-reported and granular data are needed. Improving how these data are collected will support efforts to continue to strengthen, for example, CMS OMH’s stratified reporting efforts, which currently do consider quality indicators by race and ethnicity, but at present these data are not granular and not self-reported. In addition, better quality data will allow us to validate imputation methods CMS currently uses for race and ethnicity, to ensure that we do not rely on methodologies that unintentionally create or exacerbate disparities.
As CMS moves towards stratified reporting of quality measures and addressing healthcare inequity, highlighted by the COVID-19 pandemic, the ability to analyze disparities across Medicare programs and policies depends on the ability to access and collect reliable race and ethnicity data consistently from Medicare Part C and Part D plans. The recent Executive Orders (EO) 13985 on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government and EO 14031 on Advancing Equity, Justice, and Opportunity for Asian Americans, Native Hawaiians, and Pacific Islanders, have focused attention on the need for CMS to improve the collection and quality of its enrollees’ race and ethnicity data, especially at the disaggregated level.
Participants in the cognitive interviews are people enrolling in a Medicare Advantage or Prescription Drug plan during the 2023 Medicare Advantage Open Enrollment Period (MAOEP), 2024 Medicare Open Enrollment Period (OEP), or individuals who quality for a Special Enrollment Period (SEP) and who chose not to respond, i.e., did not complete, the Section 2 voluntary questions on race and ethnicity. There are several different groups of participants by type of enrollment. There is a group of people who completed the enrollment form because they switched plans during the Medicare Advantage OEP or MA-OEP. The second group includes individuals who completed a new enrollment in a Medicare Advantage or Prescription Drug plan during the 2024 Medicare OEP. The third group is those with a qualifying event who become eligible for Medicare mid-year. CMS intends to focus participant recruitment and interviews on people enrolling during the 2023 MA-OEP but can extend information collection to include people enrolling during the 2024 Medicare OEP or throughout the benefit year.
Data collection through the interviews will be used by CMS staff to understand drivers of nonresponse to the race and ethnicity items and, where possible, make changes to strengthen the race and ethnicity data collected through the enrollment form, for example, including more response options.
CMS OMH contracted with NORC at the University of Chicago (NORC) to assist with Reducing Health Disparities through Quality Improvement. NORC was tasked to use its expertise in the Medicare population and qualitative data collection to assess nonresponse on enrollment forms. NORC will conduct the interviews, analyze the results, and develop recommendations for CMS to consider for improving response to race/ethnicity questions on program enrollment forms.
The respondent universe will include Medicare enrollees newly enrolling or switching from Part C and/or Part D plans in the 2023 calendar year that do not elect to answer the race/ethnicity questions on the enrollment form that is expected to be in place starting January 1, 2023 (OMB No. 0938-1378). In the 2022 cycle, there were about 4.28 million people that switched or newly enrolled in MA plans and another 2.52 million people that switched or newly enrolled in Part D plans. We assume a similar number of people will also switch or newly enroll in the 2023 calendar year during the MA Open Enrollment Period (Jan 1 – Mar 31), Open Enrollment Period (Oct 15 – Dec 7), and as people become eligible for Medicare. NORC will ask CMS for a list of new and existing enrollees who switched plans in April 2023 and January 2024 to capture the MA Open Enrollment Period and Open Enrollment Period as the two different enrollment populations may differ. NORC will look at how respondents that do and do not answer the race/ethnicity question differ on certain characteristics (e.g., age, gender, plan name (i.e., parent organization), region). Based upon the identified characteristics, NORC statisticians will stratify participants.
The total target number of completed interviews is 120, 60 for Part C and 60 for Part D, or until saturation is reached. Interviews will also conclude by June 2024 to allow for timely review of the results to inform enrollment form design. From previous experience conducting interviews for the Medicare Current Beneficiary Survey (MCBS), 20-30 interviews have been sufficient to identify patterns. Conducting 60 interviews for Part C and 60 for Part D should account for the stratification variables that may be used. We will reserve 40 interview slots across Part C and Part D to be completed for Wave 2 (enrollment during July – Dec 2023).
Assuming 50% have missing race/ethnicity data and 50% of the 6.8 million enroll in the first part of the year, we estimate a universe of 1.7 million people for the first set of interviews and another 1.7 million for the second set. The samples will draw from their respective universe. The expected response rate is based on the 2020 MCBS panel. In Fall 2020 the panel had a 41.9% response rate. Given that our target population elected to not respond to the race/ethnicity questions and are likely to not want to discuss their reasonings, we estimate a more conservative expected response rate of 35%. The MCBS response rate includes only 35% of phone numbers connecting interviewers to respondents as the MCBS uses a batch locating service to identify phone numbers. This suggests pulling an initial sample of approximately 250 for the first wave of interviews to account for a 35% response rate. The proposed plan for the first set of interviews is to release 40 people for each Part (80 total) to assess the response rate, with the remaining 170 sampled enrollees to be released as needed during the interview period (i.e., as an enrollee is changed from active to unreachable, the interviewer will receive a new enrollee to start contacting).
KFF Distribution of Medicare Beneficiaries by Race/Ethnicity https://www.kff.org/medicare/state-indicator/medicare-beneficiaries-by-raceethnicity
HHS OIG Report: Inaccuracies in Medicare's Race and Ethnicity Data Hinder the Ability To Assess Health Disparities https://oig.hhs.gov/oei/reports/OEI-02-21-00100.asp
CMS submission to OMB: https://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=202211-0938-013
Click on IC List for questionnaires and analysis plan, View Supporting Statement for technical documentation. Submit comments through this site.
FR notice inviting public comment: https://www.federalregister.gov/d/2022-25738
For AEA members wishing to submit comments, "A Primer on How to Respond to Calls for Comment on Federal Data Collections" is available at https://www.aeaweb.org/content/file?id=5806