In 2003, there were 120,974 and 135,757 respondents to the FFS (63.9 percent response rate) and MA (80.2 percent response rate) surveys, respectively, that met our inclusion criteria (). After weighting the data to be representative of the Medicare program nationally, roughly half of the study population was between 65 and 74 years old, just over half was female, about one-fifth had completed at least some college, one-third reported excellent or very good health, and just over 14 percent was enrolled in MA plans. High-intensity markets spent about 1.5 times the lowest-intensity markets and had more health care resources per capita: 1.17 times the number of physicians, 1.52 the number of specialists, and 1.30 times the hospital beds per person (). HRRs in the fifth quintile were concentrated in Texas, Pennsylvania, New York, New Jersey, Michigan, Illinois, Florida, and California.
Medicare Beneficiary and Hospital Referral Region Characteristics by Quintile of Service Use Intensity
For all (FFS and MA) beneficiaries across the 306 markets, problems with access to care, including how often beneficiaries were taken to the exam room within 15 minutes of a scheduled appointment (adjusted correlation [R]=−0.64, p<.001), getting care quickly (R=−0.47, p=.05), and getting care when needed (R=−0.12, p<.031) were more frequent in high-intensity areas than in low-intensity markets (). Beneficiaries in high-intensity markets also more frequently reported problems getting assistance from physician office staff (R=−0.48, p<.001) and with quality of communication with the physician (R=−0.10, p=.01) than those in low-intensity markets (). Beneficiaries in higher-intensity markets rated their personal physicians more highly than their counterparts in lower-intensity markets (R=+0.23, p<.001), but overall ratings of care and specialist were not significantly related to intensity. Finally, beneficiaries in higher-intensity markets reported receiving of flu (R=−0.46, p<.001) and pneumonia shots (R=−0.49, p<.001) less often ().
Correlations between 2003 Market Service Use Intensity and Reports of Medicare Beneficiary Experiences with Care*
also shows analyses stratified by Medicare sector. Findings for FFS beneficiaries in the 199 markets with MA enrollment were similar to those in the combined analyses. As indicated by the correlations, effect sizes for differences between the highest and lowest spending markets for FFS beneficiaries were greatest for being taken to the exam room within 15 minutes of their appointment (2.47), how helpful office staff were (1.38), and overall rating of their personal physician (1.03) ().
Effect Size for Lowest versus Highest Quintiles of Service Use Intensity in Medicare MA HRRs
MA beneficiaries in higher-intensity markets, however, reported worse experiences than those in lower-intensity markets for almost every measure ( and and ). Like FFS respondents, MA beneficiaries in higher-intensity markets had more difficulty getting care quickly (R=−0.33), being taken to the exam room within 15 minutes of their appointment (R=−0.59), and getting help and respectful treatment by office staff (R=−0.43) than their MA counterparts in lower-intensity markets (p<.0001 for all). Unlike FFS beneficiaries, however, MA beneficiaries in higher-intensity markets also reported lower overall ratings of their specialist (R=−0.20, p<.001) and care overall (R=−0.24, p<.001), as well as worse communication with their doctor (R=−0.22, p<.002) and more delays getting care while waiting for approval from their health plan (R=−0.33, p<.001) than MA beneficiaries in low-intensity markets. Effect sizes for differences between the highest- and lowest-spending quintiles for MA beneficiaries were greatest for being taken to the exam room within 15 minutes of their appointment (2.07), helpfulness of office staff (1.47), and getting needed care (1.33) ().
Patient Reported Experiences Negatively Related to Intensity of Service Use in Medicare Advantage (MA) and Fee-for-Service (FFS)
Patient Reported Experiences Negatively Related to Intensity of Service Use in Medicare Advantage (MA) But Not Fee-for-Service (FFS)
In general, the difference between the average FFS and MA beneficiary experience is larger in high-intensity markets than in lower-intensity markets, where patient-reported experiences are relatively similar (). For almost all measures across all markets FFS performance is better than MA performance (). The exceptions were, “How often were you taken to the exam room within 15 minutes of your appointment?” and receipt of pneumonia and flu vaccines; for these, MA beneficiaries report more favorable experiences than FFS beneficiaries across levels of intensity ().
Sensitivity analysis revealed that beneficiaries in markets in the highest quintile of intensity reported significantly poorer experiences for five measures (overall ratings of personal physician, specialist, care, getting care quickly, and helpful and courteous office staff) than would be expected from the trend across the rest of the markets in one or both of the programs. This poor performance in the top quintile of markets does not appear to be due to a small set of outlying poorly scoring areas because standard deviations of area means were fairly similar across quintiles of intensity.
Correlations of patient experiences with the ACI were similar to those with the EOL-EI intensity index, although in some cases they were smaller. Including beneficiaries under the age of 65 and Medicaid eligibles yielded similar relationships between experiences and intensity of care with the exception of getting care quickly, whose correlations became insignificant among the overall Medicare population (R=−0.10, p=.071) and FFS beneficiaries in markets with MA (R=−0.10, p=.146).