National Center for Health Statistics National Ambulatory Medical Care

National Center for Health Statistics National Ambulatory Medical Care Survey: Planning for the Future Denys T. Lau, Ph.D. Director, Division of Health Care Statistics Carol J. DeFrances, Ph.D. Deputy Director, Division of Health Care Statistics Presentation to the NCHS Board of Scientific Counselors January 10, 2020 1

Agenda Division of Health Care Statistics Overview NAMCS Overview – Unique strengths Changing Health Care Systems and Data NAMCS: Planning for the Future – Goal for today: Start the discussion on where to go with NAMCS. 2

Division of Health Care Statistics Overview 3

Mission Division of Health Care Statistics – Produce accurate, objective, nationally-representative statistics on health care to inform health care policy and serve a variety of research needs 4

National Health Care Surveys: Spectrum of Care Ambulatory and Hospital Care Physician offices Community health centers Emergency dept. Outpatient dept. Ambulatory surgery locations Inpatient dept. National Ambulatory Medical Care Survey (NAMCS) National Hospital Ambulatory Medical Care Survey (NHAMCS) National Hospital Discharge Survey (NHDS) 1973-ongoing 1992-ongoing 1965-2010 National Hospital Care Survey (NHCS) 2011-ongoing Long-Term Care Residential care Adult day services Nursing homes Home health Hospice care National Study of Long-Term Care Providers (NSLTCP) 2012-2019 Plus. Inpatient rehab facilities LTC hospitals National Post-Acute and LongTerm Care Study (NPALS) 2020-ongoing 5

NAMCS Overview 6

NAMCS: Purpose NAMCS is designed to meet the need for objective, reliable information about the provision and use of ambulatory medical care services in the United States. 7

NAMCS: Milestones 1973: NAMCS begins 1989: Annual data collection begins 1985: U.S. Census Bureau starts data collection 2012: Computerized data collection begins; CHC sites sampled 2006: CHC grantees sampled 2020: Still going! 2016-2017: Electronic health record data, along with abstracted data 8

NAMCS: Physician Scope Physicians must: – Be classified by AMA or AOA as primarily engaged in office-based care – Not be federally-employed – Not specializing in anesthesiology, radiology, or pathology – Not be an intern, resident, or fellow Visits must: – Be for medical purposes 9

NAMCS: Physician Sampling Process AMA Physician Universe (N 1.2 million) AOA Physician Universe (N 34 thousand) AMA Sampling Frame (n 700 thousand) AOA Sampling Frame (n 30 thousand) AMA NAMCS Sample (n 2,750) AOA NAMCS Sample (n 250) NAMCS Physician Sample (n 3,000) 10

NAMCS: Physician Data Collection Process NAMCS Sampled Physician Physician Induction Interview Sampled Calendar Week Sample of Weekly Visits (Assigned prior to fielding) (Drawn on site) Patient Visit Data Abstraction (n 30) 11

NAMCS: CHC Scope Community health centers (CHCs) must meet one of the following criteria: – Receive grant funds from the federal government through Section 330 of the Public Health Service Act – Be a look-alike CHC that meets all the requirements to receive Section 330 grant funding, but does not receive a grant – Be an Urban Indian Health Center CHC Providers include: – Physicians – Physician assistants – Nurse practitioners – Certified nurse midwives 12

NAMCS: CHC Sampling Process HRSA CHC Universe (N 14 thousand) HRSA CHC Sampling Frame (n 7.5 thousand) NAMCS CHC Sample (n 104) 13

NAMCS: CHC Data Collection Process CHC Sampled Provider 1 NAMCS Sampled CHC CHC Facility Induction Interview (includes listing of providers) Sampled Calendar Week Sample of Weekly Visits (Assigned prior to fielding) (Drawn on site) CHC Provider 1 Induction Interview CHC Sampled Provider 2 Patient Visit Data Abstraction (n 30) Sampled Calendar Week Sample of Weekly Visits (Assigned prior to fielding) (Drawn on site) CHC Provider 2 Induction Interview CHC Sampled Provider 3 CHC Provider 3 Induction Interview Patient Visit Data Abstraction (n 30) Sampled Calendar Week Sample of Weekly Visits (Assigned prior to fielding) (Drawn on site) Patient Visit Data Abstraction (n 30) 14

NAMCS: Strengths Only nationally-representative survey of physicians and CHCs – Sampling procedures yield representative estimates of both officebased physicians and CHCs Visit-level data collected directly from the source – Trained field representatives abstract data directly from medical records Various clinical data elements – Patient demographics, reasons for visit, diagnoses, procedures, medications, immunizations, and laboratory/diagnostic tests 15

NAMCS: Strengths (cont.) Provider characteristics – Can be analyzed independently and with visit-level data Sponsored content with other federal agencies – EHR adoption and interoperability, alcohol screening and brief intervention, STI prevention/PrEP, complementary health approaches Some experience with EHR data collection – EHR data collected from some physicians in 2016 and 2017, along with abstracted data from others 16

NAMCS: Importance Analysis of trends in care utilization and practice over time – Diagnoses, reasons for visit, laboratory tests, procedures, services, and medications Benchmarking and assessment – National, regional, and state-specific (2012-2015) estimates – Healthy People objectives Study of health disparities – Patient demographic characteristics and geographical differences 17

NAMCS: Uniqueness Relative to Other Sources Physician surveys – Example: AMA physician surveys – Self or proxy reported data from physician, but no clinical data Provider electronic health record databases – Example: Optum EHR and claims/EHR integrated databases – Not nationally representative data of commercially insured and Medicare Advantage enrollees, based on selected EHR vendors and health plans Ambulatory medication/drug prescription databases – Example: IQVIA National Disease and Therapeutic Index – Propriety data on only prescriptions dispensed in retail pharmacies with limited information about provider or patient 18

Importance of NAMCS: Recent Examples 19

Changing Health Care Systems and Data 20

Changing Systems Settings of care for ambulatory services have changed. – Urgent care centers and retail health clinics Ambulatory care providers have changed. – Advanced practice providers, such as nurse practitioners and physician assistants Physician offices are more complex. – Healthcare practices, conglomerates, hospital-owned groups Ambulatory care is no longer provided only in person. – Telemedicine, e-health, and other off-site care provided via other technological means 21

Yield Changing Data Increased reporting requirements – Need to show value relative to other reporting systems EHR adoption by physicians and CHCs – Impacts how data are stored and collected for NAMCS – Additional stakeholders (EHR vendors, health information exchanges, health IT staff) – New ways to process, edit, store, code, and analyze data Data security and confidentiality – Increased concern by health care providers over security – Increased involvement of legal departments 22

NAMCS Response Rates Response and participation rates are decreasing – Similar to other surveys, but with unique challenges and considerations Percentage Participant & Response Rates (unweighted): NAMCS, 2005-2018 100 90 80 70 60 50 40 30 20 10 0 66.2 61.5 Participant Rate Response Rate 41.4 32.4 40.8 37.0 Year Participant rate Physicians who completed the Induction Interview and (if seeing patients during the sampled week) gave at least one visit record / eligible physicians Response rate Physicians who completed the Induction Interview and (if seeing patients during the sampled week) gave at least half the 23 expected visit records / eligible physicians

NAMCS: Planning for the Future 24

NAMCS: 2020 and 2021 Update survey and materials – Streamline Induction Interviews to collect only a minimum amount of information – Update advance letters, create promotional videos, update participant website Incentives – Explore both monetary and non-monetary Recruitment – Target large health care practices and conglomerates, hospital-owned groups Complementary/alternative sources of sampling physicians – Explore other frames such as NPPES and SK&A to draw a sample of physicians – Strategies for sample frame maintenance 25

NAMCS: Ideas for the Future Decide on the need and relevance for NAMCS – Identify data gaps on ambulatory care and methods to fill those gaps Defining ambulatory care – Include different methods of care delivery – Include telemedicine due to the decreasing need for “traditional” face-to-face visits Providers and settings – Expand NAMCS to collect data from providers other than physicians – Collect data from settings other than physician offices and CHCs 26

NAMCS: Ideas for the Future (cont.) Reintroduce EHR data collection – Use National Health Care Surveys registrants to collect data via the HL7 CDA Implementation Guide – Explore collection of EHR data from CHCs Sample approach – Target individual providers, health care groups, or EHR vendors – Use other databases, perhaps combining multiple ones – Collect visit data for full calendar year, quarters, or months – Use overlapping, multi-year panels of respondents Explore data linkage – Collect personally identifiable information (PII) to enable linkage – Explore linkage to National Death Index, CMS claims data, and other sources 27

Questions for Discussion Is NAMCS still needed? What changes are needed to ensure its relevance? What is ambulatory care? What is direct patient care? Should physicians be limited to office-based practices? How would nurse practitioners and physician assistants be included in a future NAMCS? Should NCHS move NAMCS data collection toward all EHR? Some EHR and some abstraction? Should NAMCS employ an overlapping multi-year panel design? Should NCHS expand data collection from a sampled week to a month, a quarter, or a year? Should PII be collected to gauge repeat visits and for data linkage? 28

Moving Forward Interest in forming an NCHS Board of Scientific Counselors workgroup to discuss the future of NAMCS in more detail? 29