Health care use varies widely across the United States.1
Medicare beneficiaries in some regions receive much more intensive health care, including more office visits, greater use of specialists, more tests, and more hospital-based care than beneficiaries in other areas of the country. Not surprisingly, Medicare spending per beneficiary in 2005 (adjusted for age, race, sex, health status, and price) ranged from $5,358 in Salem, Oregon, to more than $14,000 in Miami, Florida.2
What is surprising is that patients’ health and demographic differences do not appear to account for much of the variation. 3
Given that regions with higher utilization rates have a greater supply of specialists, hospital and intensive care unit (ICU) beds, and other technologies than regions with lower rates, some have argued that the supply of medical resources, not medical necessity, accounts for variation in use among the Medicare population.4
Much of the work on regional variation has focused on either the demand-side factors of health status and sociodemographic characteristics, or the supply-side factors of supplier-induced demand and practice-style variations. 5
However, as noted by John Bertko, understanding variations in use also requires measuring the role of patients’ preferences for care.6
If patients in some regions of the country prefer to see more specialists, to be treated in an intensive care unit (ICU), and to undergo more diagnostic testing, then specialists and hospital beds have tended to migrate toward regions where patients demand the most intensive care, and providers’ practice rates in these areas may simply be a response to high levels of patient demand.7
Patients’ preferences for care seeking and their expectations about health care services may stem both from a desire for information or psychosocial support and from more specific expectations for particular tests or treatments. 8
Such expectations and preferences have been shown to affect utilization both directly and indirectly through doctor-patient communication and patients’ compliance and satisfaction, but it is unclear whether patients’ care-seeking preferences vary regionally or contribute to regional variation in utilization.9
Although the importance of patients’ preferences to high-quality care is widely recognized, only a few studies have looked at the relationship between those preferences and regional variations in utilization.10
A positive association between patients’ preferences and regional utilization levels could be both cause and effect of system characteristics. That is, not only might differences in patients’ preferences lead to higher utilization patterns, but also, since patients in high-utilization regions encounter a system much more likely to provide tests and specialty care, it would not be surprising for such patients to come to prefer high levels of tests and visits. Cross-sectional data cannot tease apart this chicken-and-egg problem, but a better understanding of the role of patients’ preferences in utilization may help to better evaluate the potential impact of policy recommendations that target patients’ utilization behavior versus provider-side actions.
In this paper we use survey data from a national sample of elderly Medicare beneficiaries in the United States to examine whether and how patients’ care-seeking preferences are associated with their use of physician visits, and to what extent differences in preferences can account for regional utilization patterns. We also explore whether patients’ perceptions of unmet need vary across regions.