Development and Applications of a Health Equity Summary Score Using the Medical Expenditure Panel Survey

Author

Ronald R. Sanchez, CUNY School of Public HealthFollow

Date of Degree

11-24-2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (Ph.D.)

Department

Community Health and Social Sciences

Advisor(s)

Sean J. Haley

Committee Members

Mustafa Hussein

Robin Moon

Subject Categories

Community Health and Preventive Medicine | Health Services Administration | Health Services Research | Public Health

Keywords

Health disparities, patient experience, clinical quality, composite measure, Medical Expenditure Panel Survey (MEPS), preventable ED visits for ambulatory care-sensitive conditions (ACSC), Patient-Centered Medical Home (PCMH), Health Equity Summary Score (HESS)

Abstract

Despite sustained national efforts, disparities in healthcare delivery persist among racial and ethnic minorities, low-income individuals, and socially at-risk populations. Monitoring modifiable aspects of care delivery, such as the structures and processes that health systems can directly improve, is a key strategy for addressing these gaps. However, most measures evaluate modifiable aspects of care delivery separately, limiting understanding of how improvements in one domain reinforce the other and how their combined effect influences equitable care.

This dissertation addresses this gap by combining patient experience and clinical quality, two modifiable aspects of care that captures how patients interact with the health system and how well providers deliver evidence-based services, into a single composite measure for use among the general U.S. adult population. We then examine how this composite score relates to preventable emergency department visits across racial and ethnic groups and evaluates the association between the composite score and organizational features of advanced primary care.

In paper 1, we construct the Medical Expenditure Panel Survey Health Equity Summary Score (MEPS-HESS) by adapting the Centers for Medicare & Medicaid Services Health Equity Summary Score (CMS-HESS) using nationally representative Medical Expenditure Panel Survey (MEPS) data for the general U.S. adult population. This paper applies a scalable approach for combining patient experience and clinical quality using routinely collected, standardized indicators. This approach fills a gap by providing a composite measure that reflects aspects of care delivery health systems can directly improve (i.e., patient experience, and clinical quality). To construct the MEPS-HESS, we created separate composite scores for patient experience and clinical quality using variables reflecting experience of care and preventive services, respectively. We then combined all variables from these two components to produce the overall MEPS-HESS score. We found that the patient experience component showed adequate internal consistency, the clinical quality component showed lower consistency, and the overall MEPS-HESS demonstrated acceptable internal consistency across all patient experience and clinical quality variables. Additionally, the MEPS-HESS was positively correlated with its component measures and provided estimates across racial and ethnic groups that were different than either patient experience or clinical quality scores alone. This contribution expands the availability of composite measures to the general adult population by providing a practical, interpretable, and scalable tool for measuring disparities in healthcare delivery.

Paper 2 assesses whether the MEPS-HESS is associated with potentially preventable emergency department visits for ambulatory care–sensitive conditions – an indicator of how effective outpatient care is able to manage chronic conditions and reduce avoidable acute care use – and examines whether this association differs by race and ethnicity. We found that higher MEPS-HESS scores were associated with lower odds of a preventable ED visit among non-Hispanic Whites; that non-Hispanic Asians and Hispanics had lower odds of an ED visit compared to non-Hispanic Whites at a MEPS-HESS score of zero, reflecting the lowest combined patient experience and clinical quality; and that the protective association of higher MEPS-HESS scores was smaller for non-Hispanic Black/African Americans and Hispanics than for non-Hispanic Whites at equivalent MEPS-HESS scores. This contribution demonstrates how a composite measure of modifiable aspects of healthcare delivery, such as the MEPS-HESS, can explain whether higher performance on both patient experience and clinical care is associated with reductions in avoidable ED use and whether this associations is comparable across population groups.

Paper 3 examines whether receiving services consistent with the Patient-Centered Medical Home (PCMH) model is associated with higher combined patient experience and clinical quality as measured by the MEPS-HESS. We constructed a PCMH score using respondent-reported items that capture PCMH-like services, including comprehensive, patient-centered, and accessible care. We found that the MEPS-HESS was modestly and positively correlated with receiving PCMH-like services. This contribution provides evidence that receiving PCMH-like services may jointly improve patient experience and clinical quality and underscores the role of primary care infrastructure in strengthening healthcare delivery.

These findings demonstrate that a composite measure such as the MEPS-HESS can help policymakers, payers, and health systems monitor disparities, identify differences in modifiable aspects of care, and target interventions to groups most affected by disparities. Advancing equitable care requires improving quality and experience while addressing non-healthcare drivers such as access barriers and socioeconomic disadvantage. By focusing on modifiable care processes, the MEPS-HESS can highlight where healthcare improvements are insufficient and where social factors shape disparities in care. This dissertation provides a generalizable framework for measuring health disparities and highlights that comprehensive measurement of healthcare delivery alongside assessment of the broader social context is needed to achieve health equity.

Recommended Citation

Sanchez, Ronald R., "Development and Applications of a Health Equity Summary Score Using the Medical Expenditure Panel Survey" (2025). CUNY Academic Works.
https://academicworks.cuny.edu/sph_etds/120