United States Government Accountability Office

GAO Report to Congressional Committees

MEDICARE 

PHYSICIAN 

SERVICES 

Use of Services 

Increasing Nationwide 

and Relatively Few 

Beneficiaries Report 

Major Access 

Problems 

July 2006 

 

GAO-06-704 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

July 2006

MEDICARE PHYSICIAN SERVICES

Use of Services Increasing Nationwide 

and Relatively Few Beneficiaries Report 

Major Access Problems 

Highlights of GAO-06-704, a report to 

congressional committees 

Congress, policy analysts, and 

groups representing physicians 

have periodically raised concerns

that Medicare’s efforts to control 

spending on physician services by

limiting annual updates to 

physician fees could have an 

adverse impact on beneficiaries’

access to physician services. These

concerns were heightened in 2002

when Medicare’s formula for 

setting physician fees required a 

5.4 percent reduction in fees to

help moderate rapid spending

increases. From 2003 to 2006, fees 

have not grown as rapidly as the 

estimated cost to physicians of

providing services, and concerns 

about access have remained. 

The Medicare Prescription Drug, 

Improvement, and Modernization 

Act of 2003 requires GAO to study 

access to physician services by 

beneficiaries in the traditional feefor-service (FFS) program. This 

report focuses on (1) trends and 

patterns in beneficiaries’ 

perceptions of the availability of 

physician services from 2000

through 2004, (2) trends in 

beneficiaries’ utilization of 

physician services from 2000

through 2005, and (3) indicators of

physician supply and willingness to 

serve Medicare beneficiaries from 

2000 through 2005. GAO analyzed 

the most recent data available, 

including several years of data 

from an annual survey of FFS 

Medicare beneficiaries as well as

utilization trends based on all 

Medicare physician claims for 

services provided in April of each

year from 2000 through 2005. 

From 2000 through 2004, among beneficiaries who needed access to 

physician services, the percentages reporting major difficulties—that is, 

“having a big problem” finding a personal provider or specialist or never 

being able to schedule an appointment promptly—remained relatively 

constant. Nationwide, no more than about 7 percent of beneficiaries 

reported a major access difficulty. We identified certain beneficiary 

characteristics—including health status, age, and race—that were associated

with beneficiaries’ reporting major access difficulties. 

In general, from April 2000 to April 2005, an increasing proportion of 

beneficiaries received physician services and an increasing number of 

physician services were provided to beneficiaries who were treated (see

figure). This trend was evident in every state’s urban areas and nearly every

state’s rural areas. 

Two other access related indicators—the number of physicians billing 

Medicare for services and the proportion of services for which Medicare’s 

fees were accepted as payment in full—increased from April 2000 to April 

2005. These increases suggest that there was no reduction in the 

predominant tendency of physicians to accept Medicare patients and 

payments. 

The increases in utilization and complexity of services GAO observed 

demonstrate that beneficiaries were able to access physician services.

However, GAO did not determine the medical appropriateness of these 

increases. Although access to appropriate care is important, the implications 

of these trends in utilization for the long-term fiscal sustainability of the 

Medicare program would require careful examination. 

CMS agreed with GAO’s findings and conclusions, stating that the analysis

was well-conceived and executed. CMS also provided technical comments, 

which GAO incorporated as appropriate. 

Trends in Access to Physician Services, April 2000 through April 2005 

Note: Beneficiaries and services were included if services were received in the first 28 days of April.

www.gao.gov/cgi-bin/getrpt?GAO-06-704.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact A. Bruce 

Steinwald at (202) 512-7101 or 

steinwalda@gao.gov. 
Contents 

Letter 1

Results in Brief 5

Background 6

Overall Trends in Beneficiary Perceptions of Major Access 

Difficulties Were Stable over Time, with Some Beneficiaries 

More Likely Than Others to Report Difficulties 13 

From 2000 to 2005, Both Proportion of Beneficiaries Receiving 

Physician Services and Number of Services Provided per 

Beneficiary Increased 24 

From 2000 to 2005, Indicators of Physician Supply and Willingness 

to Serve Medicare Beneficiaries Were Favorable 37 

Concluding Observations 40 

Agency and Industry Comments and Our Evaluation 40 

Appendix I Methods and Models Used in Analyzing Factors 

Affecting Medicare Beneficiaries’ Perceptions 

of Access 44 

Appendix II Methods Used to Analyze Medicare Claims Data 52 

Appendix III Specific Physician Services Reviewed 54 

Appendix IV Comments from the Centers for Medicare & 

Medicaid Services 56 

Appendix V GAO Contact and Staff Acknowledgments 61 

Tables 

Table 1: Example of Medicare Payment and Beneficiary 

Coinsurance for Physician Services When the MedicareApproved Amount Is $100 11 

Page i GAO-06-704 Medicare Beneficiary Access
Table 2: Medicare Beneficiary Responses to Three CAHPS Survey 

Questions regarding Access to Physician Services, 

2000-2004 14

Table 3: Average Percentage of Medicare Beneficiaries Who 

Reported Major Difficulties Accessing Physician Services 

by Self-Reported Health Status, 2000-2004 20 

Table 4: Average Percentage of Medicare Beneficiaries Who 

Reported Having Major Difficulties Accessing Physician 

Services by Beneficiary Age Group, 2000-2004 21 

Table 5: Average Percentage of Medicare Beneficiaries Who 

Reported Having Major Difficulties Accessing Physician 

Services by Race, 2000-2004 22 

Table 6: Average Percentage of Medicare Beneficiaries Who 

Reported Having Major Difficulties Accessing Physician 

Services by Supplemental Health Insurance Coverage, 

2000-2004 23

Table 7: Changes in Volume and Complexity of Physician Services 

Provided per Medicare Beneficiary, April 2000-April 2005 37 

Table 8: CAHPS Survey Questions Related to Physician Access, 

2000-2004 45

Table 9: Estimated Effects of Selected Medicare Beneficiary and 

Area Characteristics on Reporting Major Difficulty 

Accessing Physician Services, 2000-2004 47 

Table 10: Percentage Change in the Number of Services Provided 

per 1,000 Medicare Beneficiaries, April 2000 to April 2005 54 

Figures 

Figure 1: Variation by State in Percentage of Medicare 

Beneficiaries Who Reported Having a Big Problem 

Finding a Personal Doctor or Nurse, 2004 16 

Figure 2: Percentage Point Change in Medicare Beneficiary Reports 

of Having a Big Problem Finding a Personal Doctor or 

Nurse, 2000 to 2004 18 

Figure 3: Percentage of Medicare Beneficiaries Receiving Physician 

Services in April, 2000-2005 25 

Figure 4: Variation by State Urban and Rural Areas in Proportion of 

Medicare Beneficiaries Receiving Physician Services, 

April 2005 26 

Figure 5: Percentage Point Change from 2000 to 2005 in Proportion 

of Medicare Beneficiaries Receiving Physician Services in 

April, by State Urban and Rural Areas 28 

Page ii GAO-06-704 Medicare Beneficiary Access
Figure 6: Number of Physician Services Provided per 1,000 

Medicare Beneficiaries Served in April, 2000-2005 29 

Figure 7: Variation by State Urban and Rural Areas in the Average 

Number of Physician Services Provided per 1,000

Medicare Beneficiaries Served, April 2005 30 

Figure 8: Change from 2000 to 2005 in Number of Physician 

Services Provided per 1,000 Medicare Beneficiaries in 

April, by State Urban and Rural Areas 32 

Figure 9: Number of Physician Services Provided per 1,000 

Medicare Beneficiaries in April, 2000 and 2004 33 

Figure 10: Number of Services Provided per 1,000 Medicare 

Beneficiaries in April, by Service Category, 2000 and 2005 34 

Figure 11: Number of Office Visits per 1,000 Medicare Beneficiaries 

in April by New and Established Patients, 2000-2005 35 

Figure 12: Number of Physicians Billing Medicare for Services

Provided to Medicare Beneficiaries in April, 2000-2005 38 

Figure 13: Proportion of Physician Services by Medicare 

Participation and Assignment Status, April 2000 and 

April 2005 39 

Page iii GAO-06-704 Medicare Beneficiary Access
Abbreviations 

AMA American Medical Association 

ARF Area Resource File 

BETOS Berenson-Eggers Type of Service 

CABG coronary artery bypass graft 

CAHPS Consumer Assessment of Health Plans Study 

CAT computed axial tomography 

CMS Centers for Medicare & Medicaid Services 

E&M evaluation and management 

FFS fee-for-service 

FQHC federally qualified health center 

GDP gross domestic product

HSC Center for Studying Health System Change 

MedPAC Medicare Payment Advisory Commission 

MEI Medicare Economic Index 

MSA metropolitan statistical area 

MVPS Medicare volume performance standard 

NCH National Claims History file 

RHC rural health clinic 

RVU relative value units 

SGR sustainable growth rate 

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Page iv GAO-06-704 Medicare Beneficiary Access
United States Government Accountability Office

Washington, DC 20548 

July 21, 2006

Congressional Committees 

Since the early 1990s, Congress, policy analysts, and groups representing 

physicians have periodically raised concerns that Medicare’s efforts to 

control spending on physician services by limiting annual updates to 

physician fees could have an adverse impact on beneficiaries’ access to 

physician services. These concerns were heightened in 2002, when 

Medicare’s formula for setting physician fees required a 5.4 percent 

reduction in fees to help moderate rapid spending increases for physician

services.1

 In 2003 through 2006, a combination of administrative and

legislative changes averted additional fee declines that would otherwise 

have occurred under the formula. However, concerns about access 

remained because fees in these years did not grow as rapidly as the 

increase in the estimated cost to physicians for providing their services.2

 In 

the absence of additional actions, Medicare’s formula is projected to 

reduce physician fees by approximately 5 percent each year for 9 years 

beginning in 2007.3

In January 2005, we reported that based on beneficiaries’ utilization of 

physician services, the 2002 fee cut did not appear to have an immediate 

impact on beneficiary access to physician services and that beneficiary 

 1

For example, in February 2002, shortly after the fee reduction went into effect, two 

congressional hearings on Medicare physician payments were held. See Medicare Payment

Policy: Ensuring Stability and Access Through Physician Payments, Hearing Before the 

Subcommittee on Health of the Committee on Energy and Commerce, House of

Representatives, February 14, 2002, Serial No. 107-91, Washington, D.C., and Physician

Payments, Hearing Before the Subcommittee on Health of the Committee on Ways and 

Means, House of Representatives, February 28, 2002, Serial No. 107-70, Washington, D.C. 

2

The change in the cost of providing physician services is measured by the Medicare 

Economic Index (MEI). MEI measures input prices for resources needed to provide

physician services. It is designed to estimate the increase in the total cost for the average

physician to operate a medical practice. 

3

The Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary 

Medical Insurance Trust Funds, 2006 Annual Report of the Boards of Trustees of the 

Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds 

(Washington, D.C.: May 1, 2006). 

Page 1 GAO-06-704 Medicare Beneficiary Access
access increased from April 2000 to April 2002.4

 Our report did not assess, 

however, how beneficiary access to physician services might have 

changed since 2002 or how beneficiaries perceived their access to 

physician services. 

The Medicare Prescription Drug, Improvement, and Modernization Act of 

2003 directed us to study access to physician services by beneficiaries in 

the traditional fee-for-service (FFS) program.5

 Specifically, we examined 

• trends and patterns in beneficiaries’ perceptions of the availability of 

physician services from 2000 through 2004, 

• trends in beneficiaries’ utilization of physician services from 2000 through 

2005, and 

• indicators of physician supply and willingness to serve Medicare 

beneficiaries from 2000 through 2005. 

In addressing these objectives, we analyzed the most recent data available 

from two data sources. First, we analyzed several years of data from an 

annual Centers for Medicare & Medicaid Services (CMS) patient 

satisfaction survey of FFS Medicare beneficiaries, called the Consumer 

Assessment of Health Plans Study (CAHPS®).6

 Specifically, we examined 

beneficiaries’ responses for the years 2000 through 2004 to three questions 

related to access to physician services.7

 The survey questions asked 

whether 

• finding a personal provider was “no problem,” “a small problem,” or “a big 

problem”; 

• seeing a specialist was “no problem,” “a small problem,” or “a big 

problem”; and 

 4

GAO, Medicare Fee-for-Service Beneficiary Access to Physician Services: Trends in

Utilization of Services, 2000 to 2002, GAO-05-145R (Washington, D.C.: Jan. 12, 2005). 

5

Pub. L. No. 108-173, § 604, 117 Stat. 2066, 2301-02. 

6

CAHPS is a registered trademark of the Department of Health and Human Services’ 

Agency for Healthcare Research and Quality. CAHPS refers to a family of surveys that asks 

consumers and patients to evaluate their health care using a standardized set of questions. 

CMS conducts a CAHPS survey of both the Medicare FFS population and the Medicare 

Advantage population. Throughout this report we refer to the FFS CAHPS ® survey as the

CAHPS survey. Beginning in 2005, the CAHPS acronym stands for Consumer Assessment of 

Healthcare Providers and Systems. 

7

Between 100,000 and 125,000 individuals responded to the survey each year. 

Page 2 GAO-06-704 Medicare Beneficiary Access
• beneficiaries were able to schedule an appointment for routine care 

promptly “always,” “usually,” “sometimes,” or “never.” 

We measured access problems based only on beneficiaries’ responses in 

the most negative category—that is, “a big problem” or “never.” This 

approach enabled us to be as definitive as possible in describing 

beneficiaries’ perceptions of access difficulties.8,9,10 Because the personal 

provider and prompt appointment questions were not limited to physician 

services, the proportion of beneficiaries who reported major difficulties 

for these questions may not be specific to difficulties accessing physicians. 

We also sought to determine whether certain characteristics, such as age,

race, health status, and supply of physicians in a beneficiary’s county of 

residence—15 beneficiary and area characteristics in all—were associated 

with the survey responses. To determine these relationships, we 

conducted a multivariate statistical analysis that yields an estimate of each 

characteristic’s effect, controlling for the effects of all other 

characteristics in the analysis. (See app. I for more details on the 

methodology of our analysis of the CAHPS data.) 

 8

Throughout this report, we describe beneficiaries’ collective responses to the CAHPS

survey questions as their perceptions of access. 

9

Throughout this report, we collectively characterize the most negative responses to these 

three questions as “having major difficulties.” 

10Our pattern of results would have been similar if we had analyzed the three questions for 

reports of any problem, that is, a “small problem” or “big problem” and “sometimes” or 

“never.” 

Page 3 GAO-06-704 Medicare Beneficiary Access
Second, we analyzed utilization trends for 6 years by examining all 

Medicare physician claims for services provided in April of each year from 

2000 through 2005.11,12,13 These data encompass several periods: 2 years in 

which fee increases were greater than the increase in the estimated cost of 

providing services (2000 and 2001), 1 year in which fees decreased (2002), 

and 3 years in which fee increases were less than the increase in the 

estimated cost of providing services (2003, 2004, and 2005). Because it was 

outside the scope of our study, we did not adjust the claims data for 

factors that could affect the provision and use of physician services, such 

as incidence of illness or coverage of new benefits. Thus, we could not 

determine whether the amount of physician services provided over our 

period of study was appropriate. We also used the claims data to analyze 

trends in the number of physicians billing Medicare and in the proportion 

of services for which Medicare was accepted as payment in full. (See 

app. II for more details on our analysis of the Medicare claims data.) 

We ensured the reliability of the CAHPS and claims data used in this 

report by performing appropriate electronic data checks and by 

interviewing agency officials who were knowledgeable about the data.

Specifically, we examined the accuracy and completeness of the CAHPS 

data by testing for implausible values and internal consistency and by 

interviewing experts at CMS about whether the CAHPS data could 

appropriately be used as we intended. The Medicare claims data we used 

are considered to be generally reliable, as they are used by the Medicare 

program as a record of payments to health care providers and are closely

monitored by both CMS and the Medicare carriers—contractors that 

 11We examined over 60 million claims for April of each year. These claims samples from the

month of April represent an annual snapshot of beneficiary access to physician services for 

each of the 6 years. Physician fee updates generally occur at the beginning of each calendar 

year and remain constant throughout the year. We selected April to allow time for the 

annual fee updates to be implemented and for physician behavior to adjust to the new fees. 

To avoid “calendar bias”—that is, the occurrence of more weekdays in April in one year

compared to another—and to create an equal number of weekdays in each year’s data set, 

we limited each year’s claims to services performed within the first 28 days of the month. 

12We defined physician services to include those services provided by a medical doctor and 

paid under the physician fee schedule—such as office visits, major and minor surgeries,

and imaging services. We also included anesthesia services. We excluded claims for 

services provided by nurse practitioners, physician assistants, and other nonphysician 

practitioners. 

13We excluded beneficiaries in Guam, Puerto Rico, and the U.S. Virgin Islands because 

access issues in these areas may be substantively different than those in the rest of the

United States. 

Page 4 GAO-06-704 Medicare Beneficiary Access
process, review, and pay claims for Part B-covered services. In addition, 

we examined the claims data files for obvious errors, missing values, 

values outside of expected ranges, and dates outside of expected time 

frames. We also interviewed experts at CMS who regularly use the claims 

data for evaluation and analysis. We found that both the CAHPS and 

claims data were sufficiently reliable for the purpose of our analyses. We

conducted our work from October 2004 through June 2006 in accordance 

with generally accepted government auditing standards. 

From 2000 through 2004, among beneficiaries who needed access to 

physician services, the percentages reporting major difficulties—that is, 

“having a big problem” finding a personal provider or specialist or never 

being able to schedule an appointment promptly—remained relatively 

constant. Nationwide, relatively few beneficiaries—no more than about 

7 percent—reported a major access difficulty. Beneficiaries living in urban 

areas and beneficiaries living in rural areas reported major access 

difficulties in similar percentages. Although the proportion of beneficiaries 

who reported major difficulties varied considerably among states—by as 

much as 12 percentage points—their perceptions over time of access to 

physician services in the vast majority of states remained nearly the same 

or improved. In our analysis of beneficiary subgroups, we identified 

certain beneficiary characteristics—including health status, age, and

race—that were associated with beneficiaries’ reporting a big problem 

finding a personal provider or specialist or never being able to schedule an

appointment promptly. Specifically, survey respondents who rated their 

health as poor, were under 65 and disabled, were not white, and had no 

supplemental health insurance or had supplemental insurance from 

Medicaid, were more likely to have experienced physician access 

difficulties. 

Two indicators of beneficiary access to physician services—the 

proportion of beneficiaries who received services and the number of 

services provided to beneficiaries who were treated—suggest an increase 

in access from April 2000 to April 2005. In particular, the proportion of 

beneficiaries receiving services rose by 4 percentage points nationwide—

from about 41 percent to about 45 percent; by 4 percentage points in urban 

areas—from about 42 percent to 46 percent; and by 3 percentage points in

rural areas—from about 39 percent to about 42 percent. Moreover, the 

average number of services provided per 1,000 beneficiaries nationwide 

rose by 14 percent, in urban areas by 15 percent, and in rural areas by 

12 percent. Likewise, within every state’s urban areas and almost every 

state’s rural areas, the proportion of beneficiaries who received services 

Results in Brief 

Page 5 GAO-06-704 Medicare Beneficiary Access
increased, and within all states’ urban and rural areas, the average number 

of services provided to beneficiaries who received services increased. 

Volume generally increased, for specific services—office visits, 

procedures, imaging services, and tests. Finally, services per beneficiary 

rose not only in number but also in complexity for the April 2000-April 

2005 period we examined. 

Two other access related indicators—the number of physicians billing 

Medicare for services and the proportion of services for which Medicare’s

fees were accepted as payment in full—increased from April 2000 to April 

2005. Specifically, the number of physicians billing Medicare increased by 

11 percent, while the number of Medicare beneficiaries increased by 

8 percent, over the period covered by our claims analysis. In addition, 

from April 2000 through April 2005, the vast majority of Medicare services 

were performed by participating physicians—that is, physicians who 

accept Medicare’s fees as payment in full for services provided. This 

proportion increased over this period from 95 percent to over 96 percent.

The increase suggests that there was no reduction in the predominant 

tendency of physicians to accept Medicare patients and payments. 

CMS agreed with our findings and conclusions, stating that our analysis of 

existing data was well-conceived and executed. Officials from the 

American Medical Association (AMA) stated that our analysis of survey, 

claims, and physician participation data showed no deterioration in 

beneficiaries’ access to physician services over the time period studied. 

However, AMA officials cautioned that the results of this analysis should 

not be interpreted as an improvement in access and suggested that the

report place more emphasis on our finding that beneficiaries with certain 

characteristics, such as those in poor health, were more likely, relative to

other beneficiaries, to respond that they experienced major difficulty 

accessing physician services. CMS and AMA also provided technical 

comments, which we incorporated as appropriate. 

Medicare is the federally financed health insurance program for persons 

age 65 and over, certain individuals with disabilities, and individuals with 

end-stage kidney disease. In 2005 there were approximately 43 million 

Medicare beneficiaries.14 Eligible individuals are automatically covered by 

Background 

 14In 2005, 42.5 million people were covered by Medicare: 35.8 million were age 65 and older, 

and 6.7 million were disabled. 

Page 6 GAO-06-704 Medicare Beneficiary Access
Part A, which helps pay for inpatient hospital, skilled nursing facility, and 

hospice care, as well as home health care that follows a stay in a hospital 

or skilled nursing facility. Most eligible individuals elect to pay a monthly 

premium—$88.50 a month in 2006—to obtain Medicare Part B coverage, 

which helps pay for physician services, hospital outpatient services, and

certain other services, such as physical therapy.15 In addition, most 

Medicare beneficiaries have supplemental insurance that helps them pay 

for their care, thus reducing financial barriers to obtaining care. In 2002, 

90 percent of Medicare beneficiaries obtained supplemental coverage 

either through their former employer (32 percent), a privately purchased

supplemental insurance policy known as Medigap (26 percent), Medicaid 

(16 percent), or some other program. 

Medicare beneficiaries may choose how they receive covered services. In

2005, most beneficiaries in Part B—about 87 percent—were enrolled in 

Medicare’s traditional FFS option and could obtain care from any licensed 

provider willing to accept Medicare patients. The remaining beneficiaries 

were enrolled in private health plans that contract to serve Medicare 

beneficiaries and could obtain care through their health plans. These plans 

typically contract with some of the same physicians and hospitals that 

participate in FFS Medicare. 

Over the last several years, rapid spending growth for Part B services—

driven in part by spending growth for physician services—has heightened

concerns about the Medicare program’s long-range fiscal outlook. 

Medicare spending for physician services has increased from about 

$32 billion in 1998 to about $59 billion in 2005. We and others have noted 

that because of demographic trends and increases in per beneficiary 

health care spending, the Medicare program in its present form is not 

sustainable. Long-term projections indicate that Medicare’s burden on the 

federal budget and the economy will balloon—almost tripling by 2035 and 

quadrupling by 2075.16 Moderating spending growth for physician services, 

in part by seeking to ensure that services provided are necessary and 

appropriate, will continue to be part of the larger effort to ensure future 

program sustainability. 

 15In 2005, about 93 percent of the 43 million individuals covered by Medicare were enrolled 

in Part B.

16Medicare spending in 2005 was 2.7 percent of the gross domestic product (GDP) and is

projected to grow to 7.5 percent of GDP by 2035 and 12.9 percent of GDP by 2075. 

Page 7 GAO-06-704 Medicare Beneficiary Access
The provision of more services does not necessarily mean better health 

care or better health care outcomes. The wide geographic variation in 

Medicare spending for physician services—unrelated to beneficiary health

status or outcomes—provides evidence that health needs alone do not 

determine spending. Furthermore, some studies have shown that in some 

instances growth in the number of services provided may lead to medical

harm.17 Payments under the Medicare program, however, generally do not

foster quality, efficiency, or medical efficacy. Therefore, some of the 

growth in beneficiary utilization of, and spending for, physician services 

may not be warranted. Although access to appropriate care is important, 

overutilization of services represents wasteful spending and may, in some 

instances, harm beneficiaries. Consequently, policymakers have deemed it 

both reasonable and desirable to question the appropriateness of current 

and projected spending on physician services, and to explicitly consider 

the affordability of such spending when setting physician fees. 

In the 1990s, several reforms to Medicare physician fees were

implemented to help control rapid spending growth for physician services 

in the traditional FFS Medicare program. Among those reforms were the 

establishment of a national fee schedule and a system of spending 

targets.18 The target system was designed to control Medicare physician 

spending growth attributable to increases in the number of services, 

known as volume, and in the complexity and costliness of services, known 

as intensity. Under the design of the fee schedule and target system, 

annual updates to physician fees depend, in part, on whether actual 

spending has fallen below or exceeded the target. Fees are permitted to 

increase at least as fast as the costs of providing physician services as long 

as volume and intensity growth remains below a specified rate—currently, 

a little more than 2 percent a year. If spending associated with volume and 

Some Medicare Spending 

for Physician Services May 

Be Unnecessary 

Efforts to Control 

Medicare Spending on 

Physician Services Include 

Fee Schedule and 

Spending Targets 

 17Elliott S. Fisher and H. Gilbert Welch, “Avoiding the Unintended Consequences of Growth 

in Medical Care: How Might More Be Worse?” Journal of the American Medical

Association, vol. 281, no. 5 (1999): 446-453; E.S. Fisher, et al., “The Implications of Regional 

Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care,” 

Annals of Internal Medicine, vol. 138, no. 4 (2003): 273-287; E.S. Fisher, et al., “The 

Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and 

Satisfaction with Care,” Annals of Internal Medicine, vol. 138, no. 4 (2003): 288-298; and 

Joseph P. Newhouse, Free for All? Lessons from the RAND Health Insurance Experiment

(Cambridge, Mass.: Harvard University Press, 1993). 

18The first system of spending targets, the Medicare volume performance standard (MVPS), 

was established along with the fee schedule in 1992. In 1998, the sustainable growth rate

(SGR) system replaced MVPS. SGR is the current spending target system. 

Page 8 GAO-06-704 Medicare Beneficiary Access
intensity grows faster than the specified rate, the target system reduces fee 

increases or causes fees to fall. 

Under the fee schedule, Medicare pays for more than 7,000 services that 

can be classified in several broad categories—patient evaluation and 

management, which includes office visits, hospital visits, and 

consultations; procedures, which includes inpatient and minor surgeries; 

imaging, which includes X rays and more sophisticated diagnostic 

radiology, such as computed axial tomography (CAT) scans; and tests, 

which includes urinalysis and blood chemistries. Within these broad 

categories are varying levels of service complexity. 

The fee schedule expresses this complexity through relative value units 

(RVU), which account for the amount of physician time, expertise, and 

resources required to deliver a service compared to other services.19,20 The 

relative complexity—as measured by the costliness—of each service is 

compared to a benchmark service, defined as a midlevel office visit. For 

example, if a midlevel office visit had an RVU value of 1.000,21 a service 

with 1.475 RVUs is estimated to be 47.5 percent more costly to provide 

than the midlevel office visit; while a service with 0.925 RVUs is estimated 

to be 7.5 percent less costly than the midlevel office visit. In this way, RVU 

weights quantify the complexity of services provided. 

Medicare’s Physician Fee 

Schedule Based on 

Relative Values 

 19Some services paid under the physician fee schedule do not have RVUs associated with 

them; these services are priced by Medicare’s claims administration contractors. 

20Medicare adjusts a service’s RVU-based payment for area differences in physicians’ cost 

of operating a private medical practice. The adjustment is made using geographic practice

cost indexes.

21In 2005, the RVUs for a midlevel office visit were 1.39 for services provided in a nonfacility setting and 0.94 for services provided in a facility setting. 

Page 9 GAO-06-704 Medicare Beneficiary Access
Traditional FFS Medicare generally pays physicians a predetermined 

amount for each service provided. Physicians who “accept assignment” 

agree to accept Medicare’s fee as payment in full for the services they 

provide to Medicare beneficiaries. This includes the coinsurance amount 

(usually 20 percent) paid by the beneficiary to the physician.22 Physicians 

who sign Medicare participation agreements—referred to as participating 

physicians—must accept assignment for all the covered services they

provide to beneficiaries. Physicians who do not sign participation 

agreements—referred to as nonparticipating physicians—can either opt to 

accept assignment on a service-by-service basis or not at all. When a 

nonparticipating physician accepts assignment the fee schedule amount, 

also known as the Medicare-approved amount, is reduced by 5 percent.

Medicare pays the physician 80 percent of the reduced amount; the 

beneficiary pays 20 percent of the reduced amount. When a

nonparticipating physician does not accept assignment, the Medicareapproved amount is also reduced by 5 percent, but the physician is 

allowed to collect an additional amount from the beneficiary that more 

than offsets the 5 percent fee reduction—a practice known as balance 

billing.23 Specifically, nonparticipating physicians who do not accept

assignment can charge up to 15 percent over the reduced Medicare 

approved amount and thus receive in total approximately 109 percent of

the Medicare approved fee for that service (this amount is known as the 

“limiting charge”).24 The beneficiary typically has to pay the 

nonparticipating physician the full amount of the limiting charge. Medicare 

later reimburses the beneficiary for 80 percent of the reduced Medicare 

approved amount. (See table 1.) 

Medicare’s Payments to 

Physicians for Services Are 

Affected by Physician 

Participation and 

Assignment Status of 

Claim 

 22Although beneficiaries are responsible for this amount, most Medicare FFS

beneficiaries—about 90 percent in 2002—have supplementary coverage that covers out-ofpocket expenses, including the beneficiary’s coinsurance amount. 

23Physicians may “opt out” of the Medicare program altogether and charge any amount for 

the services they provide but they must inform the beneficiary in advance of this 

arrangement. Under this option, physicians must agree not to file any Medicare claims for 

2 years, and their patients are responsible for 100 percent of the charges. Relatively few 

physicians—approximately 5,000 as of 2005—have opted out of the Medicare program. 

24The limiting charge is 115 percent of 95 percent of the Medicare approved amount, or

109.25 percent.

Page 10 GAO-06-704 Medicare Beneficiary Access
Table 1: Example of Medicare Payment and Beneficiary Coinsurance for Physician Services When the Medicare-Approved

Amount Is $100 

Participating physician

Physician accepting

assignment but not

participating

Physician not accepting

assignment 

Amount charged $150 $150 $150

Medicare-approved amount $100 $95 $95

Limiting charge (15 percent 

more than the Medicareapproved amount) 

Not applicable Not applicable $109.25

Medicare payment (80 percent) $80 $76 $76

Beneficiary coinsurance 

(usually 20 percent) 

$20 $19 $33.25a

How payment is made Medicare directly pays 

physician. Beneficiary pays 

coinsurance.

Medicare directly pays 

physician. Beneficiary pays 

coinsurance. 

Beneficiary pays physician

limiting charge. Medicare 

reimburses beneficiary for its 

share (80 percent of the 

approved amount).

Source: GAO analysis of CMS information. 

a

The beneficiary pays the coinsurance of $19.00 plus the $14.25 difference between the Medicare 

payment to the physician and the limiting charge. 

Studies of Medicare 

Beneficiary Access 

Suggest Few Problems 

Nationwide 

Studies from the Medicare Payment Advisory Commission (MedPAC), 

CMS, and the Center for Studying Health System Change (HSC) have 

reported that Medicare beneficiary access to physician services 

nationwide has been good in recent years, with some exceptions. In its 

March 2006 report,25 MedPAC reported the results of its 2005 survey 

comparing patient access measures between Medicare beneficiaries and 

privately insured individuals age 50 to 64. It found that similar proportions 

of Medicare and privately insured individuals had no problems finding a 

physician or scheduling an appointment. Specifically, 75 percent of both 

Medicare beneficiaries and of privately insured individuals had no problem 

finding a new primary care physician,

26 while 74 percent of Medicare 

beneficiaries and 67 percent of privately insured individuals never 

 25See Medicare Payment Advisory Commission, Report to the Congress, Medicare Payment

Policy (Washington, D.C.: March 2006). 

26In 2005, 12 percent of Medicare beneficiaries had a small problem and 13 percent had a

big problem finding a new primary care physician. Similarly, 16 percent of privately insured

individuals had a small problem and 9 percent had a big problem finding a new primary

care physician. 

Page 11 GAO-06-704 Medicare Beneficiary Access
experienced an unwanted delay in getting an appointment for routine 

care.27 These results are generally consistent with previous MedPAC 

reports on access related solely to Medicare beneficiaries.28

In 2005, CMS reported findings from its “targeted” beneficiary survey, that

is, a survey focused only on beneficiaries in 11 markets who might have

been likely to experience problems accessing physician services based on 

evidence from CMS monitoring activities and responses to the 2001 

CAHPS survey.29,30 The survey results generally showed stability or 

improvement in obtaining access from 2003 through 2004. For example, 

the proportion of FFS Medicare beneficiaries who reported that seeing a 

doctor “has gotten harder in the past year or two” remained the same—at 

7 percent—for both years. In addition, the proportions of beneficiaries 

reporting problems getting routine care appointments in 2003 and 2004 

declined from 27 percent to 21 percent. CMS also noted that certain 

groups of beneficiaries—those transitioning to a new physician, disabled 

individuals, those in poor or fair health, those with low incomes, and those 

without supplemental coverage—had higher rates of problems accessing 

physician services. For example, about 10 percent of disabled (under 

age 65) Medicare beneficiaries reported access problems related to 

physicians’ willingness to accept Medicare, whereas no more than 

4 percent of beneficiaries older than 65 (and therefore eligible for 

Medicare on the basis of age) reported the same problem. 

A January 2006 HSC report, based on periodic surveys of physicians, found 

that the proportion of physicians nationwide accepting new Medicare 

 27In 2005, with regard to getting an appointment for routine care, 21 percent of Medicare 

beneficiaries sometimes experienced an unwanted delay, 3 percent usually experienced an

unwanted delay, and 2 percent always experienced an unwanted delay. Similarly, among

privately insured individuals, 25 percent sometimes, 5 percent usually, and 3 percent

always experienced an unwanted delay in getting an appointment for routine care. 

28See Medicare Payment Advisory Commission, Report to the Congress, Medicare Payment

Policy (Washington, D.C.: March 2005); Report to the Congress, Medicare Payment Policy

(Washington, D.C.: March 2004); Report to the Congress, Medicare Payment Policy

(Washington, D.C.: March 2002); and Report to the Congress, Medicare Payment Policy

(Washington, D.C.: March 2000). 

29Centers for Medicare & Medicaid Services and Mathematica Policy Research, Inc., Results 

from the 2003 and 2004 Targeted Beneficiary Surveys on Access to Physician Services

Among Medicare Beneficiaries (Washington, D.C.: Jan. 20, 2005). 

30The 11 markets included the state of Alaska; Phoenix, Arizona; San Diego, California; San 

Francisco, California; Denver, Colorado; Tampa, Florida; Springfield, Missouri; Las Vegas,

Nevada; Brooklyn, New York; Fort Worth, Texas; and Seattle, Washington. 

Page 12 GAO-06-704 Medicare Beneficiary Access
patients remained unchanged for the two most recent survey periods.31,32

Specifically, for both the 2000-2001 and 2004-2005 survey periods, HSC 

found that over 70 percent of physicians surveyed accepted all new 

Medicare patients.33 Only a small fraction—less than 4 percent—of 

physicians responded that they did not accept any new Medicare patients.

HSC concluded that despite fluctuations in Medicare payments to 

physicians, access has remained high for beneficiaries and comparable to 

access rates for privately insured individuals. 

From 2000 through 2004, the percentage of beneficiaries who reported 

major difficulties accessing physician services—that is, “having a big 

problem” finding a personal provider or specialist or never being able to 

promptly schedule a routine appointment—did not vary much from year to 

year, and relatively small percentages of beneficiaries reported these 

difficulties. The percentage of beneficiaries who reported major 

difficulties accessing physician services varied widely by state, but in the 

vast majority of states this percentage remained relatively constant or 

declined from 2000 through 2004. Beneficiaries living in urban areas and 

beneficiaries living in rural areas reported major access difficulties in 

similar percentages. However, beneficiaries with certain characteristics—

such as those in poor health or less than 65 years of age—were more likely 

to report access difficulties relative to other beneficiaries regardless of 

where they lived. 

Overall Trends in

Beneficiary 

Perceptions of Major 

Access Difficulties 

Were Stable over 

Time, with Some

Beneficiaries More 

Likely Than Others to 

Report Difficulties 

 31Center for Studying Health System Change, Tracking Report: Physician Acceptance of 

New Medicare Patients Stabilizes in 2004-2005 (Washington, D.C.: January 2006).

32The HSC Community Tracking Study Physician Survey is a nationally representative 

telephone survey of physicians involved in direct patient care in the continental United

States. The survey had three data collection periods, 1996-1997, 2000-2001, and 2004-2005. 

33If the proportion of physicians who accepted “some” or “most” new patients had been

included, the percentage would have been higher. 

Page 13 GAO-06-704 Medicare Beneficiary Access
The percentage of beneficiaries who reported major difficulties accessing

physician services did not vary substantially from 2000 through 2004. (See 

table 2.) For example, among those who needed to find a personal doctor 

or nurse,34 about 7 percent of beneficiaries reported a big problem in 2000, 

and about 5 percent reported a big problem in 2004. Similarly, among 

those who needed to see a specialist,35 the percentage of beneficiaries who 

reported having a big problem varied by less than 2 percentage points—

from a high of 5.6 percent in 2000 to a low of 4.3 percent in 2004. Among 

beneficiaries who needed to schedule an appointment,36 the percentage

who reported never being able to schedule an appointment promptly 

remained at less than 2 percent throughout the 5-year period.

Proportions of 

Beneficiaries Reporting 

Major Access Difficulties 

Were Relatively Small and 

Stable

Table 2: Medicare Beneficiary Responses to Three CAHPS Survey Questions

regarding Access to Physician Services, 2000-2004 

Percentage of respondents who 

reported having major difficulties CAHPS survey questions regarding 

access to physician services 2000 2001 2002 2003 2004

How much of a problem was it finding a 

personal doctor or nurse you were happy 

with since enrolling in Medicare? 7.1 5.6 6.0 5.8 5.3

In the last 6 months, how much of a 

problem was it seeing a specialist? 5.6 4.6 5.0 4.9 4.3

In the last 6 months, how often did you 

get an appointment promptly? 1.1 1.1 1.6 1.5 1.5

Source: GAO analysis of CMS’s Medicare CAHPS surveys. 

Notes: We define major difficulties as reporting “a big problem” finding a personal doctor or nurse or 

seeing a specialist or as reporting “never” being able to promptly schedule a health care appointment.

These questions were paraphrased for the purposes of this report. The total number of individuals 

responding to each question varied from year to year. We reported proportions only for those 

beneficiaries who needed to find a personal doctor or nurse, needed to see a specialist, or needed to 

schedule an appointment. 

 34In each survey year, an average of 47 percent of beneficiaries reported that they did not 

have the same personal doctor or nurse as before joining Medicare. 

35In each survey year, an average of 56 percent of beneficiaries reported needing to see a 

specialist in the past 6 months. 

36In each survey year, an average of 74 percent of beneficiaries reported needing to 

schedule an appointment in the past 6 months. 

Page 14 GAO-06-704 Medicare Beneficiary Access
In each survey year, the proportion of beneficiaries who reported major 

difficulties accessing physician services varied considerably across the 

50 states and the District of Columbia. For example, in 2004, Alaska had 

the highest proportion of beneficiaries—15 percent—who reported having

a big problem finding a personal doctor or nurse, whereas Nebraska had 

the lowest, 3 percent. Figure 1 shows variation among the states in the 

percentage of beneficiaries who reported having a big problem finding a 

personal doctor or nurse in 2004. Also in 2004, the percentage who 

reported having a big problem seeing a specialist ranged from a high of 

11 percent in Alaska to a low of 2 percent in Vermont. In contrast, the 

proportion of beneficiaries who reported never being able to schedule an

appointment promptly had a smaller range—from a high of 5 percent in 

Alaska to less than 1 percent in Nebraska. In a separate analysis, we found 

that the supply of health care resources, such as physicians and hospital 

beds, did not have a sufficiently important impact on beneficiaries’ 

perceptions of access to physician services; the variation we found among 

states in the percentages reporting major difficulties should therefore not 

be interpreted as being related to the availability of health care resources. 

(See app. I.) 

Beneficiary Perceptions of 

Major Access Difficulties 

Varied by State, but Trends 

over Time Were Stable or 

Improved 

Page 15 GAO-06-704 Medicare Beneficiary Access
Figure 1: Variation by State in Percentage of Medicare Beneficiaries Who Reported Having a Big Problem Finding a Personal 

Doctor or Nurse, 2004 

Source: GAO analysis of CMS’s Medicare CAHPS survey.

2.7 to 3.9

4.0 to 5.9

6.0 to 7.9

8.0 to 14.9

Big problem finding a personal doctor or nurse

Percentage

Note: Percentages are reported only for beneficiaries who indicated in their survey responses that 

they had a different personal doctor than before they enrolled in Medicare. 

Page 16 GAO-06-704 Medicare Beneficiary Access
In the vast majority of states, the proportion of beneficiaries in 2004 who 

reported major difficulties accessing physician services was nearly the

same as, or lower than, the proportion in 2000. Specifically, in 49 states, 

the proportion of beneficiaries in each state who reported a big problem 

finding a personal doctor or nurse either stayed the same—within 

2 percentage points of that reported in 2000—or fell by more than 

2 percentage points.37 (See fig. 2.) Similarly, in all 50 states and the District 

of Columbia, the proportion of beneficiaries who reported a big problem 

seeing a specialist either stayed the same or declined. In 47 states, 

proportions of beneficiaries who reported never being able to schedule an 

appointment promptly remained the same.38

 37The proportion of beneficiaries who reported a big problem finding a personal doctor or

nurse increased from 2000 to 2004 in the District of Columbia and Idaho. 

38The proportion of beneficiaries who reported never being able to schedule an

appointment promptly increased from 2000 to 2004 in Alaska, the District of Columbia,

Idaho, and Nevada. 

Page 17 GAO-06-704 Medicare Beneficiary Access
Figure 2: Percentage Point Change in Medicare Beneficiary Reports of Having a Big Problem Finding a Personal Doctor or

Nurse, 2000 to 2004 

Source: GAO analysis of CMS’s CAHPS survey.

2.0 to 5.1 percentage point decrease

Less than 2.0 percentage point change

2.0 to 7.0 percentage point increase

Big problem finding a personal doctor or nurse

Percentage

Note: Percentage point changes are reported only for beneficiaries who indicated in their survey

responses that they had a different personal doctor than before they enrolled in Medicare. 

Page 18 GAO-06-704 Medicare Beneficiary Access
The District of Columbia and Idaho were exceptional in that beneficiaries’ 

perceptions of access grew worse from 2000 to 2004 on more than one 

question. Specifically, during that period, the proportion of beneficiaries in 

the District of Columbia who reported a big problem finding a personal 

doctor or nurse increased by 7 percentage points, and the proportion who 

reported never having scheduled an appointment promptly increased by 

3 percentage points. Over the same period, the proportions of 

beneficiaries in Idaho who reported a big problem finding a personal 

doctor or nurse and who reported never having scheduled an appointment 

promptly increased by 2 percentage points. 

Beneficiary Perceptions of 

Major Access Difficulties 

Were Similar for Urban 

and Rural Areas 

We observed very little difference between the proportions of urban and

rural beneficiaries who reported major difficulties accessing physician 

services during the period 2000 through 2004. For example, in 2004, 

5.5 percent of urban beneficiaries reported having a big problem finding a 

personal doctor or nurse, and 4.8 percent of rural beneficiaries reported a 

big problem. In that same year, 4.4 percent of urban beneficiaries and 

4.1 percent of rural beneficiaries reported having a big problem finding a 

specialist. Similarly, 1.6 percent of urban beneficiaries reported never 

being able to schedule an appointment promptly, and 1.4 percent of rural 

beneficiaries reported this difficulty. 

The proportions of both urban and rural beneficiaries who reported major 

access difficulties remained relatively stable—changing by no more than 

2 percentage points—from 2000 through 2004. For example, the 

proportion of urban beneficiaries who reported having a big problem 

finding a personal doctor or nurse ranged from a high of 7.3 percent in 

2000 to a low of 5.5 percent in 2004. Similarly, the proportion of 

beneficiaries in rural areas who reported a big problem ranged from a high 

of 6.7 percent in 2000 to a low of 4.8 percent in 2004. When asked about 

seeing a specialist, the percentage of urban beneficiaries who reported 

having a big problem was 5.6 in 2000 and 4.4 in 2004. Likewise, 5.4 percent

of rural beneficiaries reported having a big problem in 2000, as did 

4.1 percent in 2004. Finally, the proportion of urban beneficiaries who 

reported never being able to schedule an appointment promptly was 

relatively stable—1.2 percent in 2000 and 1.6 percent in 2004. Among rural 

beneficiaries, 1.0 percent and 1.4 percent reported this difficulty in 2000 

and 2004, respectively.

Page 19 GAO-06-704 Medicare Beneficiary Access
Beneficiaries with certain characteristics—fair or poor self-reported 

health status, under age 65, nonwhite, no supplemental health insurance or 

supplemental insurance from Medicaid, college-educated—were 

somewhat more likely than other beneficiaries to report major difficulties 

accessing physician services.39 For example, when asked about their ability 

to find a personal doctor or nurse they were happy with, on average over 

the 5 years, about 8 percent of beneficiaries in fair or poor health 

responded that they had a big problem, compared with about 4 percent of

beneficiaries in excellent or very good health.40 (See table 3.) On the other 

two physician access questions, those in fair or poor health similarly 

reported major difficulties more frequently on average than those in better 

health.41 This relationship between health status and reported access is 

consistent with the fact that people in fair or poor health are likely to have 

more physician encounters and thus have more opportunities to 

experience an access problem. 

Beneficiaries with Certain 

Characteristics More 

Likely Than Others to 

Report Major Access 

Difficulties 

Table 3: Average Percentage of Medicare Beneficiaries Who Reported Major Difficulties Accessing Physician Services by

Self-Reported Health Status, 2000-2004

Beneficiary selfreported health status

Percentage reporting a 

big problem finding a

personal doctor or nurse 

they were happy witha

Percentage reporting a big 

problem seeing a specialistb

Percentage reporting never 

being able to schedule an

appointment promptlyc

Excellent or very good 4.1 2.5 1.2

Good 4.8 3.4 1.2

Fair or poor 8.0 7.2 1.6

Source: GAO analysis of CMS’s Medicare CAHPS surveys. 

a

Percentages are reported for beneficiaries who reported that they did not have the same personal 

doctor or nurse before joining Medicare. 

b

Percentages are reported for beneficiaries who reported needing to see a specialist in the past 

6 months. 

c

Percentages are reported for beneficiaries who reported needing to make an appointment in the past 

6 months. 

 39Other beneficiary and area characteristics, such as sex, county of residence, and countylevel supply of physicians and hospital beds, did not affect the proportion of beneficiaries 

reporting major difficulties. (See app. I.) 

40Beneficiaries’ heath status was self-reported. 

41Fair or poor health status was associated with reporting major access difficulties even 

after we controlled for other characteristics, such as age and race. (See app. I.) In total, we

controlled for survey year and 15 beneficiary and area characteristics. 

Page 20 GAO-06-704 Medicare Beneficiary Access
Compared with respondents age 65 and over, a larger proportion of 

beneficiaries under age 65, who typically qualify for Medicare on the basis 

of disability,42 reported major difficulties accessing physician services. For 

example, on average during this period, about 11 percent of beneficiaries 

under age 65 reported a big problem seeing a specialist, compared with 

4 percent of beneficiaries over age 65.

43 (See table 4.) This relationship 

suggests that disabled beneficiaries were more likely to report having 

major physician access difficulties than beneficiaries age 65 and older. 

Table 4: Average Percentage of Medicare Beneficiaries Who Reported Having Major Difficulties Accessing Physician Services 

by Beneficiary Age Group, 2000-2004

Beneficiary age group 

Percentage reporting a 

big problem finding a

personal doctor or nurse 

they were happy witha

Percentage reporting a big 

problem seeing a specialistb

Percentage reporting never 

being able to schedule an

appointment promptlyc

Under 65 13.2 10.8 2.5

65 and overd5.1 4.0 1.2

Source: GAO analysis of CMS’s Medicare CAHPS surveys. 

a

Percentages are reported for beneficiaries who did not have the same personal doctor or nurse 

before they joined Medicare. 

b

Percentages are reported for beneficiaries who indicated that they needed to see a specialist in the 

past 6 months. 

c

Percentages are reported for beneficiaries who attempted to make an appointment in the past 

6 months. 

d

Across the age breakouts for those age 65 and over—that is, 65 to 69, 70 to 74, 75 to 79, 80 to 84,

and 85 and over—the percentage reporting having major difficulties varied little. 

Nonwhite beneficiaries were somewhat more likely to report major 

difficulties accessing physician services than white beneficiaries. For 

example, the percentage of nonwhites reporting a big problem finding a 

personal doctor or nurse, on average, was about 2 percentage points 

higher relative to whites. In addition, the percentages of nonwhites 

reporting major difficulties accessing specialists and scheduling 

 42Some beneficiaries under age 65 qualify for Medicare for other reasons, such as having

end-stage renal disease. 

43When we controlled for the effect of other characteristics, including self-reported health

status, being under age 65 was associated with reporting major access difficulties. (See

app. I.) Regardless of health status, these disabled beneficiaries reported major difficulties 

more frequently. In total, we controlled for survey year and 15 beneficiary and area 

characteristics. 

Page 21 GAO-06-704 Medicare Beneficiary Access
appointments were larger on average than the percentages of whites 

reporting major difficulties—a difference of 6 and 1 percentage points, 

respectively.

44 (See table 5.) 

Table 5: Average Percentage of Medicare Beneficiaries Who Reported Having Major Difficulties Accessing Physician Services 

by Race, 2000-2004 

Beneficiary race 

Percentage reporting a 

big problem finding a

personal doctor or nurse 

they were happy witha

Percentage reporting a big 

problem seeing a specialistb

Percentage reporting never 

being able to schedule an

appointment promptlyc

White 5.7 4.1 1.2

Black 6.4 8.9 2.1

Hispanic 8.2 11.3 2.4

Other 9.3 11.2 2.4

All nonwhite 7.5 10.1 2.3

Source: GAO analysis of CMS’s Medicare CAHPS surveys. 

a

Percentages are reported for beneficiaries who did not have the same personal doctor or nurse 

before they joined Medicare. 

b

Percentages are reported for beneficiaries who indicated that they needed to see a specialist in the 

past 6 months. 

c

Percentages are reported for beneficiaries who attempted to make an appointment in the past 

6 months. 

Medicare beneficiaries with no supplemental health insurance and those 

with Medicaid as a supplement were more likely than beneficiaries with 

only Medigap or other non-Medicaid supplemental health insurance to 

report major difficulties accessing physician services. For example, on 

average, beneficiaries with no supplemental coverage or with Medicaid 

were about 2 and about 4 percentage points, respectively, more likely than 

beneficiaries with only non-Medicaid supplemental coverage to report a 

big problem finding a personal doctor or nurse. (See table 6.) With respect

to seeing a specialist, beneficiaries with no supplemental health insurance 

or Medicaid were, on average, about 5 and 6 percentage points 

respectively, more likely to report a big problem, compared with 

 44After we controlled for other beneficiary characteristics, nonwhite race remained 

associated with reporting major access difficulties for the questions on finding a specialist 

and scheduling an appointment. (See app. I.) For the question on finding a personal doctor

or nurse, however, blacks were less likely to report a big problem than whites, and

Hispanics were as likely as whites to report a big problem after we controlled for other

beneficiary characteristics. 

Page 22 GAO-06-704 Medicare Beneficiary Access
beneficiaries with non-Medicaid supplemental coverage. Beneficiaries 

with no supplemental coverage or Medicaid were about 1 percentage point 

more likely than those with other supplemental coverage to report never 

being able to schedule an appointment promptly.45

Table 6: Average Percentage of Medicare Beneficiaries Who Reported Having Major Difficulties Accessing Physician Services 

by Supplemental Health Insurance Coverage, 2000-2004 

Supplemental health 

insurance coverage 

Percentage reporting a big 

problem finding a

personal doctor or nurse 

they were happy witha 

Percentage reporting a big 

problem seeing a specialistb

Percentage reporting never 

being able to schedule an

appointment promptlyc

None 7.5 8.9 2.1

Medicaid 8.8 9.2 1.8

Non-Medicaid 5.1 3.6 1.1

Source: GAO analysis of CMS’s Medicare CAHPS surveys. 

Note: Non-Medicaid includes supplemental coverage from the Department of Veterans Affairs, 

Tricare, Medigap, and other private insurance. Some beneficiaries included in the Medicaid 

supplemental category may also have had non-Medicaid supplemental coverage. 

a

Percentages are reported for beneficiaries who did not have the same personal doctor or nurse 

before they joined Medicare. 

b

Percentages are reported for beneficiaries who indicated that they needed to see a specialist in the 

past 6 months. 

c

Percentages are reported for beneficiaries who attempted to make an appointment in the past 

6 months. 

After we controlled for the other factors that could affect access to 

physician services,46 including health status, age, and race, beneficiaries 

who had a 4-year college degree were more likely to report major 

difficulties accessing physician services. (See app. I.) For example, a 

typical beneficiary—a white female, age 70 to 74, with a high school 

diploma—had about a 7 percent likelihood of reporting a big problem 

finding a personal doctor or nurse.47 In contrast, if the same beneficiary 

 45After we controlled for other beneficiary characteristics, lack of supplemental coverage 

from a source other than Medicaid remained associated with reporting major difficulties

accessing physician services. (See app. I.) 

46In total we controlled for survey year and 15 beneficiary and area characteristics, which 

we describe in app. I. 

47A typical beneficiary also had fair or poor self-reported health status, had supplemental 

health insurance coverage only from a source other than Medicaid, and resided in an urban

area. See app. I for a complete list of the typical characteristics—both beneficiary and area 

related. 

Page 23 GAO-06-704 Medicare Beneficiary Access
had attained a 4-year college degree, she would have slightly more than an 

8 percent likelihood of reporting a big problem finding a personal doctor 

or nurse. 

Two indicators of beneficiary access to physician services—the 

proportion of beneficiaries who received services and the number of 

services provided to beneficiaries who were treated—suggest an increase 

in access from April 2000 to April 2005. Nationwide, in urban areas and in 

rural areas, the proportion of beneficiaries receiving services rose by 3 to 

4 percentage points over this period. Moreover, the average number of 

services provided per 1,000 beneficiaries who received services rose 

nationwide by 14 percent, in urban areas by 15 percent, and in rural areas

by 12 percent. These two indicators increased within every state’s urban 

areas and almost every state’s rural areas. 

In general, the proportion of beneficiaries who received physician services 

rose during the period covered in our review. (See fig. 3.) Specifically, 

from 2000 to 2005, the proportion of beneficiaries receiving services 

during the month of April rose from about 41 percent to about 45 percent. 

Although this measure declined slightly in April 2003, the proportion of 

beneficiaries receiving services remained a percentage point higher than in

April 2000 and the upward trend resumed in 2004. Nationwide, this 

measure increased in both urban and rural areas. Specifically, the 

proportion of beneficiaries receiving services rose from about 42 percent 

in April 2000 to about 46 percent in April 2005 in urban areas and from 

about 39 percent in April 2000 to about 42 percent in April 2005 in rural 

areas. 

From 2000 to 2005, 

Both Proportion of 

Beneficiaries 

Receiving Physician 

Services and Number 

of Services Provided 

per Beneficiary 

Increased 

Proportion of Beneficiaries 

Receiving Physician 

Services Grew 

Page 24 GAO-06-704 Medicare Beneficiary Access
Figure 3: Percentage of Medicare Beneficiaries Receiving Physician Services in April, 2000-2005 

Percentage 

0 

10 

20 

30 

40 

50 

41.3 42.0 43.2 42.3 43.3 44.8

42.1 42.7 44.0 43.1

45.6

39.1 40.2 41.3

39.9 41.2 42.3

44.1

Source: GAO analysis of Medicare Part B claims and enrollment data from CMS.

2000

2001

2002

2003

2004

2005

Total Urban Rural

Note: Beneficiaries were included if they received a service in the first 28 days of April. 

In each year, the proportions of beneficiaries receiving services in April 

varied by state urban and rural areas. (See fig. 4.) For example, in 2005, the

lowest proportion of beneficiaries receiving services was 33 percent in 

urban Alaska, whereas the highest proportion was 53 percent in rural 

Delaware. The proportion of beneficiaries receiving services in April 2005 

was 40 percent or higher in almost three-quarters of the 99 urban and rural 

areas we examined.48 Specifically, within the states, in four-fifths of the 

 48Using the Office of Management and Budget’s system for defining metropolitan statistical 

areas, we classified the nation’s counties as urban or rural. We consolidated the urban

counties and rural counties in each state and the District of Columbia, and created 99

geographic areas. There were 51 urban areas and 48 rural areas. There are no rural areas in

New Jersey, Rhode Island, and the District of Columbia. 

Page 25 GAO-06-704 Medicare Beneficiary Access
urban areas and two-thirds of the rural areas, the proportion of 

beneficiaries receiving services was 40 percent or more. 

Figure 4: Variation by State Urban and Rural Areas in Proportion of Medicare Beneficiaries Receiving Physician Services, 

April 2005 

Source: GAO analysis of Medicare Part B claims and enrollment data from CMS. 

33 to 37.9 

38 to 42.9 

43 to 47.9 

48 to 53

Urban areas within states

Percentage 

Note: Beneficiaries were included if they received a service in the first 28 days of April. 

Page 26 GAO-06-704 Medicare Beneficiary Access
Within every state’s urban areas and almost every state’s rural areas, the 

proportion of beneficiaries receiving services increased from April 2000 to

April 2005. The percentage of beneficiaries receiving services increased by 

4 percentage points in urban areas and by 3 percentage points in rural 

areas. There was a slight decline—1 percentage point or less—in the rural 

areas of Hawaii and Washington. (See fig. 5.) The largest increase— 

14 percentage points—occurred in rural Alaska. In two-thirds of the 

99 areas we examined, there was at least a 3 percentage point increase 

from April 2000 to April 2005. 

Page 27 GAO-06-704 Medicare Beneficiary Access
Figure 5: Percentage Point Change from 2000 to 2005 in Proportion of Medicare Beneficiaries Receiving Physician Services in 

April, by State Urban and Rural Areas 

Source: GAO analysis of Medicare Part B claims data from CMS. 

-1.3 to 2.3

2.4 to 6.0

6.1 to 9.7

9.8 to 13.5

Urban areas within states

Percentage point change

Note: Beneficiaries were included if they received a service in the first 28 days of April. 

Page 28 GAO-06-704 Medicare Beneficiary Access
From April 2000 to April 2005, an increasing number of services were 

provided to beneficiaries who were treated by a physician. Specifically, in

that period, the average number of services provided per 1,000 

beneficiaries who were treated rose by 14 percent—from about 3,400 to 

about 3,900. From April 2000 to April 2005, the number of services 

provided per 1,000 beneficiaries was lower in rural areas (3,196 services 

per 1,000 beneficiaries who received services in 2000) relative to urban 

areas (3,516 services per 1,000 beneficiaries who received services in 

2000). (See fig. 6.) However, in percentage terms, the urban and rural areas 

experienced similar increases in the number of services per treated 

beneficiary—15 percent in urban areas, compared with 12 percent in rural 

areas. 

Average Number of 

Services Provided Rose 

Figure 6: Number of Physician Services Provided per 1,000 Medicare Beneficiaries Served in April, 2000-2005 

Services per 1,000 beneficiaries served

0 

500 

1,000 

1,500 

2,000 

2,500 

3,000 

3,500 

4,000 

4,500 

Source: GAO analysis of Medicare Part B claims and enrollment data from CMS.

2000

2001

2002

2003

2004

2005

Total Urban Rural

3,433

3,925

3,516 3,626 3,723 3,769 3,874 4,035

3,774 3,630 3,672 3,539

3,196 3,290 3,356 3,376 3,470 3,587

Note: Beneficiaries and services were included if services were received in the first 28 days of April. 

The number of services provided also varied among states’ urban areas 

and rural areas. (See fig. 7.) For example, in April 2005, the lowest number 

Page 29 GAO-06-704 Medicare Beneficiary Access
of services provided per 1,000 beneficiaries who were treated by a 

physician was 3,071 services in urban Vermont, whereas the highest 

number was 4,503 services in urban Florida. In rural areas, the number 

ranged from 3,094 services in Vermont to 4,191 in Florida. 

Figure 7: Variation by State Urban and Rural Areas in the Average Number of Physician Services Provided per 1,000 Medicare 

Beneficiaries Served, April 2005 

Source: GAO analysis of Medicare Part B claims data from CMS. 

3,071 to 3,428

3,429 to 3,786

3,787 to 4,144

4,145 to 4,503

Urban areas within states

Number of services

Note: Beneficiaries and services were included if services were received in the first 28 days of April. 

Page 30 GAO-06-704 Medicare Beneficiary Access
Within every state’s urban and rural areas, there was an increase from 

April 2000 to April 2005 in the average number of services provided for 

each beneficiary who was treated by a physician. (See fig. 8.) In 57 of the 

99 areas we examined, the number of services provided per 1,000 

beneficiaries increased by at least 12 percent. Among the 51 urban areas

we examined, the percentage increase in the number of services provided

per 1,000 beneficiaries ranged from a high of 21 percent in New York to a 

low of 3 percent in Vermont. Among the 48 rural areas, the increase ranged

from a high of 20 percent in Connecticut to a low of 4 percent in Wyoming.

Page 31 GAO-06-704 Medicare Beneficiary Access
Figure 8: Change from 2000 to 2005 in Number of Physician Services Provided per 1,000 Medicare Beneficiaries in April, by

State Urban and Rural Areas 

Source: GAO analysis of Medicare Part B claims data from CMS. 

3.0 to 7.3

7.4 to 11.7

11.8 to 16.1

16.2 to 20.6

Urban areas within states

Percentage change

Note: Beneficiaries and services were included if the services were received in the first 28 days of 

April. 

Although the CAHPS survey showed a worsening in beneficiaries’ 

perceptions of access to physician services in two states—the District of 

Columbia and Idaho—our analysis of the claims data demonstrated that 

the number of services provided to Medicare beneficiaries increased in 

both states and increased substantially in one of the two states. For 

Page 32 GAO-06-704 Medicare Beneficiary Access
example, from April 2000 to April 2004, the same period covered by the 

CAHPS surveys, we found a double-digit increase in the number of 

services provided per capita both nationwide (24 percent) and in Idaho 

(13 percent).

49 In contrast, over the same period, the number of services 

provided per capita increased by only 2 percent in the District of 

Columbia. (See fig. 9.) 

Figure 9: Number of Physician Services Provided per 1,000 Medicare Beneficiaries

in April, 2000 and 2004 

0 

200 

400 

600 

800 

1,000 

1,200 

1,400 

1,600 

1,800 

District of Idaho 

Columbia

All States

Services per 1,000 beneficiaries

Source: GAO analysis of Medicare Part B claims and enrollment data from CMS.

2000

2004

1,417 

1,635 

1,367 1,395

1,044

1,177

Notes: Services were included if they were received in the first 28 days of April. We focused on the 

two states identified by our analysis of CAHPS data as showing a worsening access problem from 

2000 to 2004. 

In examining trends in the number, or volume, of services, we found that 

volume generally increased across broad categories of services—

evaluation and management, procedures, imaging services, and tests. 

Specifically, the number of services provided per 1,000 Medicare 

beneficiaries increased in all of these categories from April 2000 to April 

 49Per capita refers to the average number of services per 1,000 Medicare beneficiaries.

Page 33 GAO-06-704 Medicare Beneficiary Access
2005. (See fig. 10.) Within the procedures category, the number of minor 

procedures provided per 1,000 beneficiaries increased by 36 percent, 

whereas the number of major procedures declined slightly by 3 percent.

Figure 10: Number of Services Provided per 1,000 Medicare Beneficiaries in April, 

by Service Category, 2000 and 2005 

0 

100 

200 

300 

400 

500 

600 

700 

800 

900 

1,000 

 

Services per 1,000 beneficiaries

Source: GAO analysis of Medicare Part B claims and enrollment data from CMS.

2000

2005

230 

304 

255 

356 

104 

160 

Evaluation Procedures Imaging Tests

and Management

827 

933

Note: Services were included if they were received in the first 28 days of April. 

In examining trends in the numbers of services provided, we also found 

that the average number of office visits—an indicator of access to the 

most basic level of physician services—generally increased (see fig. 11).50

Specifically, from 2000 to 2005, the number of office visits per 1,000 

Medicare beneficiaries received during the month of April increased from

26 visits to 28 visits for new patients (an increase of about 8 percent) and 

 50Office visits can be provided by both primary care physicians and specialists. We

examined office visits because they are the typical entry point into the health care system 

and the most basic level of physician services. 

Page 34 GAO-06-704 Medicare Beneficiary Access
from 405 visits to 454 visits for established patients (an increase of about 

12 percent).51

Figure 11: Number of Office Visits per 1,000 Medicare Beneficiaries in April by New

and Established Patients, 2000-2005 

0

100

200

300

400

500

2000 2001 2002 2003 2004 2005

Services per 1,000 beneficiaries

Source: GAO analysis of Medicare Part B claims data from CMS. 

Office visits for new patients

Office visits for established patients

26 27 28 25 26 28

405 415

431 419 431

454

Notes: Services were included if they were received in the first 28 days of April. Medicare defines an

established patient as one who has seen the same physician at least once before in the past 3 years. 

We also found that the number of specialty services provided generally

increased over the 6 years reviewed. Most of the specialty services we 

examined—such as aneurysm repairs, pacemaker insertions, and hip 

replacements—experienced double-digit growth rates. (For a complete list 

of the services we examined, see app. III.) For example, per capita growth 

in aneurysm repairs rose by about 65 percent; in pacemaker insertions, by 

about 64 percent; and in hip replacements, by about 11 percent. Moreover, 

we found double-digit per capita growth rates over the 6 years reviewed 

for services that are most likely to be affected by physician fee changes. 

 51We examined office visits separately for new and established patients to assess access to 

care trends among new patients who might be more likely to experience access difficulties. 

Page 35 GAO-06-704 Medicare Beneficiary Access
These discretionary services could be postponed without medically 

harming the patient, and therefore physicians might provide fewer of them 

when there is downward pressure on fees. For example, per capita growth 

in knee replacement procedures rose by about 47 percent; in

electrocardiograms, by about 18 percent; and in CAT scans, by about 

65 percent. Although per capita declines occurred for a few specialty 

procedures,52 these declines may have resulted for reasons other than 

access difficulties, such as physician discretion, patient acuity, or the 

ability to substitute other procedures. For example, coronary artery 

bypass grafting (CABG) declined per beneficiary by about 31 percent, 

whereas coronary angioplasty, a substitute in some cases for CABG, grew 

per beneficiary by about 34 percent.

Complexity of Services 

Provided Also Increased 

Service complexity—an element of utilization—increased from April 2000 

to April 2005. Specifically, physician services per beneficiary rose in 

complexity, as measured in average annual changes in RVUs, over this 

period. Increases in service volume occurred for each broad category of 

services—evaluation and management, procedures, imaging, and tests—

with the exception of major procedures. Similarly, for all categories of 

services, the complexity of services provided per beneficiary rose over the

same period. (See table 7.) Overall, volume rose by an average of about 

4 percent, while complexity rose by an average of about 5 percent. Thus, 

beneficiaries’ increased utilization of physician services has manifested 

itself in both increased volume and increased complexity of services for 

the 6 years reviewed. 

 52The procedures included were coronary artery bypass grafts, thromboendarterectomy, 

sigmoidoscopy, hip fracture repair, and corneal transplant. 

Page 36 GAO-06-704 Medicare Beneficiary Access
Table 7: Changes in Volume and Complexity of Physician Services Provided per 

Medicare Beneficiary, April 2000-April 2005 

Type of service

Annual percentage 

change in number 

of services per 

beneficiary, 

April 2000-April 2005 

Annual percentage 

change in

complexity of

services per 

beneficiary, as

measured in RVUs, 

April 2000-April 2005 

All services 4.4 5.2 

Evaluation and management 

services 

2.4 3.7

Procedures 5.7 4.3

Major -0.7 2.3

Minor 6.3 5.2

Imaging 6.9 10.5

Tests 9.1 13.9

Source: GAO analysis of Medicare Part B claims and enrollment data from CMS. 

Notes: Services were included in the calculation of average annual percentage changes if the 

services were received in the first 28 days of April. To account for complexity of services, we used 

RVU weights for 2005. 

Two additional access related indicators—the number of physicians billing 

Medicare for services and the percentage of services for which Medicare’s

fees were accepted as payment in full—increased from 2000 to 2005. These

increases suggest that in the aggregate, physicians continued to accept 

Medicare patients without requiring additional payments from 

beneficiaries during this period. 

From 2000 to 2005, 

Indicators of 

Physician Supply and 

Willingness to Serve 

Medicare 

Beneficiaries Were 

Favorable 

Page 37 GAO-06-704 Medicare Beneficiary Access
An increasing number of physicians billed Medicare from April 2000 to 

April 2005. (See fig. 12.) In April 2000, the number of physicians billing 

Medicare was about 419,000, and in April 2005, that number had increased 

to a little more than 467,000. While Medicare experienced an 11 percent

increase in the number of physicians billing the program, the number of 

beneficiaries in Medicare—FFS and managed care combined—rose by 

8 percent.53

Number of Physicians 

Serving Medicare 

Beneficiaries Increased 

Figure 12: Number of Physicians Billing Medicare for Services Provided to Medicare 

Beneficiaries in April, 2000-2005 

0 

100 

200 

300 

400 

500 

2000 2001 2002 2003 2004 2005 

Physicians (in thousands) 

Source: GAO analysis of Medicare Part B claims data from CMS.

419 427 437 447 456 467 

Notes: Physicians were included if they served a beneficiary in the first 28 days of April. We counted 

each occurrence of the unique physician identification number on the claim once. 

 53Because the majority of physicians serving FFS Medicare beneficiaries also likely serve 

beneficiaries in Medicare managed care, we report the change in the total number of 

Medicare beneficiaries—FFS and managed care combined. The number of FFS 

beneficiaries increased by 13 percent, an increase driven in part by a decline of about 

18 percent in the number of enrollees in managed care, from 6.8 million to 5.6 million.

Page 38 GAO-06-704 Medicare Beneficiary Access
From April 2000 to April 2005, the vast majority of Medicare physician 

services were performed by participating physicians—that is, physicians 

who formally agreed to participate in the Medicare program and submit all 

claims on assignment.54 This percentage increased from 95 percent to over 

96 percent. (See fig. 13.) During the same period, the overall percentage of

services paid on assignment—that is, services performed by both 

participating and nonparticipating physicians who accepted assignment—

also increased. In April 2000, 98.2 percent of services were paid on 

assignment, and in April 2005, 99.0 percent of services were paid on 

assignment. Fewer beneficiaries were likely to be subject to balance 

billing for physician services in 2005 than in 2000 as the percentage of 

services for which physicians were permitted to balance bill Medicare 

beneficiaries fell from 1.8 percent to 1.0 percent.

Proportion of Services for 

Which Physicians 

Accepted Medicare 

Payment in Full Increased 

Figure 13: Proportion of Physician Services by Medicare Participation and Assignment Status, April 2000 and April 2005 

95.0% 96.3% 

Source: GAO analysis of Medicare Part B claims data from CMS.

1.8% 

3.2% 

Nonparticipating/

unassigned

Nonparticipating/

assigned

Participating/assigned 

1.0% 

2.7% 

Nonparticipating/

unassigned

Nonparticipating/

assigned

Participating/assigned 

April 2000 April 2005 

Note: Services were included if they were received in the first 28 days in April. 

 54Physicians may decide on an annual basis whether they will be Medicare participating 

physicians. 

Page 39 GAO-06-704 Medicare Beneficiary Access
Although concerns have been raised that Medicare’s efforts to control 

spending on physician services might have diminished beneficiary access 

to those services, our analyses of data from 2000 through 2005 found 

access to physician services stayed the same or increased. Specifically, 

during the years we studied, relatively small proportions of beneficiaries 

reported problems accessing physician services, the percentage of 

beneficiaries who received physician services increased, and the number 

of services provided per beneficiary increased. Finally, our indicators of 

physician willingness to serve Medicare beneficiaries—the number of 

physicians billing Medicare and the proportion of services for which 

physicians accepted Medicare payment in full—help round out the picture 

of beneficiary access to services. We found that during the 2000-2005 

period covered by our claims analysis, an increasing number of physicians 

billed Medicare and an increasing number of claims were submitted “on 

assignment.” The general stability in perceptions of access problems and 

increases in other indicators of access are notable, considering that during 

all but 2 of the years examined, annual updates caused physician fees 

either to fall or to increase at rates below the increase in the estimated 

cost of providing services. 

The increases in utilization and complexity we observed demonstrate that 

beneficiaries were able to access physician services. However, we did not 

determine the medical appropriateness of these increases. A more 

complex study would be required to determine whether the increased 

utilization over the period we studied resulted in positive health outcomes 

for beneficiaries. Such analysis is important because these utilization 

trends have implications for the long-term fiscal sustainability of the 

Medicare program. 

In written comments on a draft of this report, CMS agreed with our 

findings and conclusions, stating that our analysis of existing data was 

well-conceived and executed. CMS noted the agency’s commitment to 

ensuring continued beneficiary access to care while attempting to address 

the long-term fiscal sustainability of the Medicare program. CMS said that 

it had conducted its own analyses of data from a variety of sources in 

order to identify any beneficiary difficulties in accessing physician 

services, and these analyses did not indicate a national problem accessing 

Concluding 

Observations 

Agency and Industry 

Comments and Our 

Evaluation 

Agency Comments 

Page 40 GAO-06-704 Medicare Beneficiary Access
care. CMS noted that we may want to include claims reflecting services 

performed in federally qualified health centers (FQHC) and rural health 

clinics (RHC) in any future analyses of utilization, as relying solely upon 

Part B claims from the National Claims History files may underrepresent 

utilization of physician services. However, the agency stated that including 

these claims would not substantively change GAO’s results and 

conclusions. Furthermore, we note that our utilization measures would 

change only to the extent that services provided in FQHCs and RHCs were 

performed by medical doctors, as we excluded services performed by 

nonphysicians, such as nurse practitioners and physician assistants. CMS 

also provided other comments it characterized as minor editorial and 

technical points, which we incorporated where appropriate. We have

reprinted CMS’s letter in appendix IV. 

American Medical 

Association Comments 

We obtained oral comments on our draft report from officials representing 

the AMA. The AMA officials expressed two overall concerns. First, while 

stating that our analysis of survey, claims, and physician participation data

showed no deterioration in beneficiaries’ access to physician services over

the period studied, the officials cautioned the analyses’ results should not 

be interpreted as an improvement in access. The AMA officials said that 

for example, increases in the utilization of physician services could be the 

result of beneficiaries growing sicker, the substitution of physician 

services for care in the hospital or other settings, or beneficiaries taking 

advantage of new Medicare-covered benefits. An investigation of alternate 

explanations for the growth in utilization was beyond the scope of this 

report. Although our report finds that the percentage of beneficiaries 

reporting major access difficulties remained relatively constant over the

period, that the utilization of services generally increased nationwide, and 

that physician participation in Medicare also increased, the report does 

not characterize these findings as improvements in access. Second, the 

AMA officials said that the report should place more emphasis on our 

finding that beneficiaries with certain characteristics, such as those in 

poor health, were more likely, than to other beneficiaries, to respond that 

they experienced major difficulty accessing physician services. Although 

this finding is not the focus of our report, we believe that it is accorded the 

appropriate emphasis, as it is included in the Highlights section and the 

Results in Brief. Based on other comments from AMA officials, we revised 

our draft report where appropriate. 

Page 41 GAO-06-704 Medicare Beneficiary Access
We are sending copies of this report to the Administrator of CMS, 

appropriate congressional committees, and other interested parties. We 

will also provide copies to others on request. In addition, this report is 

available at no charge on the GAO Web site at http://www.gao.gov. 

If you or your staff have questions about this report, please contact me at

(202) 512-7101 or steinwalda@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made key contributions to this report are 

listed in appendix V. 

A. Bruce Steinwald 

Director, Health Care 

Page 42 GAO-06-704 Medicare Beneficiary Access
List of Committees 

The Honorable Charles E. Grassley 

Chairman 

The Honorable Max Baucus 

Ranking Minority Member 

Committee on Finance 

United States Senate 

The Honorable Joe L. Barton 

Chairman 

The Honorable John D. Dingell 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

The Honorable William M. Thomas 

Chairman 

The Honorable Charles B. Rangel 

Ranking Minority Member 

Committee on Ways and Means 

House of Representatives 

The Honorable Nathan Deal 

Chairman 

The Honorable Sherrod Brown 

Ranking Minority Member 

Subcommittee on Health

Committee on Energy and Commerce 

House of Representatives 

The Honorable Nancy L. Johnson 

Chairman 

The Honorable Pete Stark 

Ranking Minority Member 

Subcommittee on Health

Committee on Ways and Means 

House of Representatives 

Page 43 GAO-06-704 Medicare Beneficiary Access
Appendix I: Me

A

Beneficiaries’

thods and Models Used in 

nalyzing Factors Affecting Medicare

 Perceptions of Access 

Page 44 GAO-06-704

Appendix I: Methods and Models Used in 

Analyzing Factors Affecting Medicare 

Beneficiaries’ Perceptions of Access 

This appendix explains how we analyzed beneficiaries’ perceptions of 

their ability to access physician services and factors that might contribute 

to those perceptions. First, we describe the data we analyzed from the 

Medicare Consumer Assessment of Health Plan Study (CAHPS), which 

contains indicators of fee-for-service (FFS) beneficiary perceptions of 

physician access. Next, we explain how we identified beneficiaries’ 

characteristics that were associated with their perceptions of access to 

physician services. We then describe how we reported the way those 

beneficiary characteristics were associated with major difficulties 

accessing physician services. We also explain how we identified trends in

beneficiary perceptions over time and across states. Finally, we discuss 

how we evaluated the reliability of our data and the limitations of our 

analysis. 

Data Sources To study beneficiaries’ perceived access to physician services, we used 

data from the Centers for Medicare & Medicaid Services’ (CMS) CAHPS 

FFS annual surveys administered from 2000 through 2004. The CAHPS 

survey asks beneficiaries to describe their experiences with the Medicare

FFS program. We identified these annual surveys as a nationally 

representative source of Medicare beneficiaries’ perceptions of their 

access to health care that would enable comparisons over time among 

states and between urban and rural areas. CMS surveyed over 168,000 FFS 

beneficiaries each year.1

 The response rate was at least 63 percent each 

year. 

We focused on the three CAHPS questions that were related to

beneficiaries’ access to physician services. The questions, reproduced in 

table 8, asked about beneficiaries’ ability to access a personal provider of 

care (a physician or nurse), specialists, and prompt appointments. For 

each question, we included only the responses from those beneficiaries 

who could have encountered an access problem—those who reported in a 

prior question that they in fact needed care.2

 For example, we include 

responses to the specialist access question only for those beneficiaries 

who answered in a prior survey question that they needed to see a 

 1

We excluded responses from beneficiaries residing outside the 50 states and the District of

Columbia in our analysis.

2

About 50 percent of beneficiaries indicated a need for a new personal provider. Similarly, 

about 60 percent self-reported a need for access to specialists, and about 70 percent 

indicated that they needed an appointment. 

Medicare Beneficiary Access
Appendix I: Methods and Models Used in 

Analyzing Factors Affecting Medicare

Beneficiaries’ Perceptions of Access 

specialist in the past 6 months. We calculated the proportion of 

respondents who responded the most negatively—those who responded 

that they had “a big problem” or who “never” scheduled a prompt 

appointment. This approach enabled us to be as definitive as possible in 

describing beneficiaries perceptions of access difficulties.3

Table 8: CAHPS Survey Questions Related to Physician Access, 2000-2004 

Respondents included in analysis

Percentage of all 

survey respondents Access question Response 

Beneficiaries who reported that they did 

not have the same doctor before joining 

Medicare. 

47 Since you joined Medicare, how much of a 

problem, if any, was it to get a personal 

doctor or nurse you are happy with? 

• A big problem 

• A small 

problem 

• Not a problem 

Beneficiaries who reported that they 

needed to see a specialist in the past 6 

months. 

56 In the past 6 months, how much of a 

problem, if any, was it to see a specialist 

that you needed to see? 

• A big problem 

• A small 

problem 

• Not a problem

Beneficiaries who reported that they 

needed to schedule a routine health care

appointment in the past 6 months. 

74 In the past 6 months, how often did you get 

an appointment for health care as soon as 

you wanted? 

• Never 

• Sometimes 

• Usually 

• Always 

Source: GAO analysis of CMS’s annual Medicare CAHPS surveys. 

Note: The exact wording of each question varied by survey year. 

The CAHPS survey also asked beneficiaries to provide information about 

themselves, and we used those responses to determine whether 

beneficiary characteristics were systematically associated with 

beneficiaries reporting major difficulties accessing physician services. 

Specifically, we analyzed beneficiary sex, race, age, educational 

attainment, urban or rural residence, additional health care coverage, and

self-reported health status.4

 We supplemented the CAHPS data for each

beneficiary with county-level information from the 2000 Area Resource 

 3

When we conducted the analyses described in this appendix using any negative 

responses—that is, both “big problem” and “small problem” and both “never” and 

“sometimes”—the proportions were larger, but the effects of beneficiary and area

characteristics on the likelihood of reporting a problem were about the same. 

4

Additionally, we tested whether the use of a proxy to help respondents complete the 

survey had an effect on beneficiaries’ perceptions of access. 

Page 45 GAO-06-704 Medicare Beneficiary Access
Appendix I: Methods and Models Used in 

Analyzing Factors Affecting Medicare

Beneficiaries’ Perceptions of Access 

File (ARF)5 on primary care physicians per capita, specialist physicians 

per capita, managed care penetration, per capita income, the proportion of 

the population enrolled in Medicare, hospital beds per capita, and 

ambulatory surgical centers per Medicare beneficiary.6

Analysis of Beneficiary 

Responses to the CAHPS 

Survey 

To analyze the extent to which various beneficiary and area characteristics 

were associated with perceived access to physician services, we first used

a standard statistical method of analysis known as logistic regression 

modeling to identify key beneficiary and area characteristics, and then we

computed simple proportions of beneficiaries with key characteristics 

who reported major difficulties. For example, our model showed that age

was associated with reporting major difficulties, so we reported 

percentages reporting major difficulties by age group. Logistic regression 

modeling estimates the effect of each independent variable—in this case, a 

beneficiary characteristic—on an either/or (binary) variable—in this case, 

either reporting a major difficulty or not—while holding constant the 

effects of other independent variables in the model. The size of the effect

of each beneficiary characteristic is expressed as a coefficient, which can 

be mathematically converted into an odds ratio. The odds ratio compares 

the likelihood of reporting a major difficulty when a characteristic is 

present to the likelihood of reporting a major difficulty when the 

characteristic is absent. When a characteristic is absent, the beneficiary is

classified as belonging to a “reference group.” For example, for the 

characteristic “race,” our logistic regression model compares three race 

variables—black, Hispanic, and other race—to the reference group, white. 

(See table 9.) The odds ratio of the reference group is always set equal to 

1.00. Odds ratios larger than 1.00 indicate that the presence of the 

characteristic increases the likelihood of reporting a major difficulty 

compared to the reference group, while odds ratios smaller than 

 5

The ARF, which is maintained by the Health Resources and Services Administration, is a 

county-based health resources information database that contains data from many sources,

including the U.S. Census Bureau and the American Medical Association. The ARF is a 

standard data source that is well-documented and widely used. We linked year 2000 ARF

data to beneficiaries from all 5 CAHPS survey years for two reasons. First, we reasoned 

that local area characteristics would not change much over the CAHPS survey years—2000 

through 2004. Second, some fields of ARF data were not available for 2001 through 2004.

6

In the year 2000, CAHPS data on county of residence were missing for all beneficiaries 

living in eight states—Alaska, Idaho, Montana, North Dakota, Rhode Island, South Dakota,

Wyoming, and Vermont—and the District of Columbia. These missing data rendered 3,600

beneficiaries—roughly 3 percent of the year 2000 CAHPS respondents—not linkable to the 

ARF data. 

Page 46 GAO-06-704 Medicare Beneficiary Access
Appendix I: Methods and Models Used in 

Analyzing Factors Affecting Medicare

Beneficiaries’ Perceptions of Access 

1.00 indicate that the presence of the characteristic decreases the 

likelihood of reporting a major difficulty compared to the reference group. 

We combined observations from all 5 CAHPS survey years in the logistic 

regression analysis.7

 The logistic regression models for the three access 

questions included variables for 15 beneficiary and area characteristics, 

which are listed, together with their odds ratios, in table 9. 

Table 9: Estimated Effects of Selected Medicare Beneficiary and Area Characteristics on Reporting Major Difficulty Accessing

Physician Services, 2000-2004 

Odds ration

Characteristic

Big problem 

finding a personal

 doctor or nursea

Big problem 

seeing a 

specialistb

Never scheduled

an appointment 

promptlyc

Age Under 65 1.00d1.00d1.00d

65-69 0.63** 0.61** 0.77**

70-74 0.51** 0.58** 0.56**

75-79 0.43** 0.55** 0.55**

80-84 0.36** 0.55** 0.53**

85 and over 0.30** 0.52** 0.56**

Sex Female 1.00d1.00d1.00d

Male 0.84** 0.93* 1.21**

Race White 1.00d1.00d1.00d

Black 0.83** 1.38** 1.28**

Hispanic 1.09 1.86** 1.50**

Other 1.28** 2.14** 1.64**

Self-reported health status Excellent or very good 0.80** 0.75** 0.99

Good 1.00d1.00d1.00d

Fair or poor 1.57** 1.80** 1.26**

Supplemental health insurance None 1.26** 1.91** 1.60**

coverage Medicaid 1.27** 1.64** 1.33**

Non-Medicaid 1.00d1.00d1.00d

 7

Time trends in the likelihood of reporting a major difficulty were captured by including a

variable for survey year in the model. 

Page 47 GAO-06-704 Medicare Beneficiary Access
Appendix I: Methods and Models Used in 

Analyzing Factors Affecting Medicare

Beneficiaries’ Perceptions of Access 

Odds ration

Characteristic

Big problem 

finding a personal

 doctor or nursea

Big problem 

seeing a 

specialistb

Never scheduled

an appointment 

promptlyc

Educational attainment No high school diploma 0.84** 1.04 1.03

High school diploma 1.00d1.00d1.00d

4-year college degree or more 1.25** 1.20** 1.15*

Proxy assisted in survey completion Yes 1.02 1.00 0.89*

No 1.00d

1.00d1.00d

Urban or rural residence Urban 0.99 0.91* 1.03

Rural 1.00d1.00d1.00d

Quartile of hospital beds per capita Lowest 1.09** 0.98 0.98

Second 1.03 1.03 1.06*

Third 0.96* 0.99 0.98

Highest 1.00d1.00d1.00d

Lowest 0.94* 0.93* 0.95

Second 0.89** 1.06* 0.95

Quartile of ambulatory surgical 

centers per Medicare beneficiary 

Third 1.07* 1.01 1.07*

Highest 1.00d1.00d1.00d

Lowest 0.98 1.03 1.04

Second 0.97 0.98 0.99

Quartile of primary care physicians 

per capita 

Third 1.01 0.97 0.97

Highest 1.00d1.00d1.00d

Quartile of specialist physicians per Lowest 0.90* 1.01 0.99

capita Second 1.04* 1.00 0.97

Third 1.09** 1.01 0.99

Highest 1.00d 1.00d 1.00d

Quartile of Medicare managed care Lowest 0.89** 0.88** 0.96

penetration Second 1.01 0.96* 0.94*

Third 1.05* 1.08** 0.99

Highest 1.00d1.00d1.00d

Quartile of Medicare beneficiaries per Lowest 1.11** 1.11** 1.05

capita Second 0.98 0.97 0.95*

Third 0.92** 0.94* 0.96

Highest 1.00d 1.00d 1.00d

Quartile of per capita income Lowest 1.01 1.00 0.94

Second 0.99 0.99 0.98

Third 0.98 1.01 1.03

Highest 1.00d1.00d1.00d

Page 48 GAO-06-704 Medicare Beneficiary Access
Appendix I: Methods and Models Used in 

Analyzing Factors Affecting Medicare

Beneficiaries’ Perceptions of Access 

Odds ration

Characteristic

Big problem 

finding a personal

 doctor or nursea

Big problem 

seeing a 

specialistb

Never scheduled

an appointment 

promptlyc

Year 2000 1.00d1.00d1.00d

2001 0.81** 0.88* 1.04

2002 0.88** 1.00 1.62**

2003 0.82** 0.94 1.43**

2004 0.74** 0.82** 1.46**

Source: GAO analysis of CMS’s Medicare CAHPS and ARF data. 

Legend: **= significant at the 0.0001 level; *= significant at the 0.05 level. 

Note: Bolded odds ratios indicate a value equal to or below 0.85, and equal to or above 1.15. 

Nonbolded odds ratios indicate a value from 0.85 to 1.15. 

a

These results were derived from the responses of beneficiaries who answered that they changed 

personal doctors since enrolling in Medicare—an average of 47 percent a year. 

b

These results were derived from the responses of beneficiaries who answered that they needed to 

see a specialist in the past 6 months—an average of 56 percent a year. 

c

These results were derived from the responses of beneficiaries who answered that they needed an 

appointment in the past 6 months—an average of 74 percent a year. 

d

Omitted reference group. 

Based on the results of our logistic regression analysis, we identified 

beneficiary characteristics that were associated at the 0.05 level of 

significance or better with either a substantial increased likelihood—an 

odds ratio greater than or equal to 1.15—or a substantial decreased 

likelihood—an odds ratio less than or equal to 0.85— of reporting a major 

difficulty.8

 For these characteristics, we computed a readily 

understandable measure—the percentage of respondents in each group 

who reported having a major difficulty—for each of the three survey 

questions.9

 However, for one characteristic—educational attainment of a 

4-year college degree or more—we had to use a more sophisticated 

technique to account for confounding factors. We estimated the likelihood

of a typical beneficiary reporting major difficulty finding a personal doctor 

 8

We required the characteristic to be important in the same direction—that is, an increased 

or a decreased likelihood—on at least two of the three questions related to physician 

access. 

9

For illustrative purposes, we combined black, Hispanic, and other race into one nonwhite 

category, when calculating the proportions for race, and we combined all beneficiaries 

over age 65 into one age group when calculating proportions for age.

Page 49 GAO-06-704 Medicare Beneficiary Access
Appendix I: Methods and Models Used in 

Analyzing Factors Affecting Medicare

Beneficiaries’ Perceptions of Access 

or nurse.10,11 We then compared that likelihood to the estimated likelihood 

for a beneficiary who had a 4-year college degree and who was typical in 

all other respects. 

In order to understand how reports of major difficulties accessing 

physician services changed over time and varied among states, we 

analyzed the proportion of beneficiaries reporting major difficulties on 

each of the three questions related to physician access by state of 

residence and by survey year. We also calculated these proportions for 

each survey year by all urban and rural areas in the nation. 

Data Reliability and 

Limitations 

We took several steps to ensure that the CAHPS data were sufficiently 

reliable for our analysis. We examined the accuracy and completeness of 

the data by testing for implausible values and internal consistency.12 In 

addition, we interviewed experts at CMS about whether the CAHPS data 

could appropriately be used as we intended. We concluded that the data

were sufficiently reliable for the purpose of this analysis. We conducted

our work from October 2004 through June 2006 in accordance with 

generally accepted government auditing standards. 

There were three main limitations to our analysis. First, the CAHPS 

questions on finding a personal provider and scheduling an appointment 

were not limited to physician services.13 (See table 8.) If these survey 

 10The characteristics of a typical beneficiary were female, white, age 70-74, fair or poor 

health, no proxy assistance for completion of the survey, high school diploma or some 

college, residence in an urban area, and non-Medicaid supplemental health insurance 

coverage. We assigned the study year 2003 and the second quartile of other measures, such 

as primary care physicians per capita, as beneficiary characteristics. 

11For this characteristic, we chose to report the likelihood of reporting major difficulties

finding a personal doctor or nurse for illustrative purposes; we also analyzed the likelihood 

of reporting major difficulties seeing a specialist or making an appointment promptly with 

somewhat similar results.

12In order to ensure the consistency of individuals’ responses to both the prior question on 

the need for care and the related access question, we recoded some survey responses. For 

example, if an individual answered in a prior question that he or she did not need a 

specialist, we recoded the response on the access question related to specialists to “not 

applicable.” We also excluded observations with implausible ARF values—less than 

1 percent of all observations—where complete ARF data were essential to the analysis. 

13For example, the question on finding a personal provider may include services provided

by nonphysicians, such as personal nurses. The question on scheduling an appointment 

promptly for health care may include services other than those provided by physicians. 

Page 50 GAO-06-704 Medicare Beneficiary Access
Appendix I: Methods and Models Used in 

Analyzing Factors Affecting Medicare

Beneficiaries’ Perceptions of Access 

questions had asked only about access to physician services, we likely 

would have found different proportions of beneficiaries who reported big 

problems finding a personal provider or who reported never being able to 

schedule an appointment promptly. Second, the proportions of 

beneficiaries reporting major difficulties accessing physician services may 

not be representative of the national population of Medicare 

beneficiaries.14 Finally, although we endeavored to model all of the 

important beneficiary characteristics using logistic regression, we lacked

some information that may have been important, such as beneficiary 

income. 

 14While the CAHPS is a random sample, we subset the data such that it became a 

nonprobability sample. A nonprobability sample’s statistics cannot be generalized to a 

population because some elements of the population being studied have no chance or an

unknown chance of being selected as part of the sample. 

Page 51 GAO-06-704 Medicare Beneficiary Access
Appendix II: Methods Used to Analyze Appendix II: Methods Used to Analyze Medicare Claims Data 

Medicare Claims Data 

To analyze Medicare beneficiaries’ access to physician services, through 

their utilization of services, we used Medicare Part B claims data from the 

National Claims History (NCH) files. We constructed data sets for 

100 percent of Medicare claims for physician services performed by 

physicians in the first 28 days of April of 2000 through 2005.1

 These data 

encompass several periods: 2 years in which fee increases were greater 

than the increase in the estimated cost of providing services (2000 and 

2001), 1 year in which fees decreased (2002), and 3 years in which fee 

increases were less than inflation in the estimated cost of providing 

services (2003, 2004, and 2005). We established a consistent cutoff date 

(the last Friday in September of the subsequent year) for each year’s data

file and only included those claims for April services that had been 

submitted by that date.

2

 Because claims continue to accrete in the data

files, this step was necessary to ensure that earlier years were not more 

complete than later years. We supplemented these claims files with CMS 

data on the number of beneficiaries in the FFS program as of March of 

each year from the Medicare Managed Care Market Penetration Quarterly 

State/County Data Files. In addition, on the basis of beneficiary location,

we associated each service with an urban or rural location, using the 

Office of Management and Budget’s classification of metropolitan 

statistical areas (MSA). 

We constructed several utilization measures to determine whether 

Medicare beneficiaries experienced changes in their access to physician 

services; these indicators included 

• the percentage of Medicare FFS beneficiaries obtaining services in April of 

each year,3

• the total number of physician services received, and 

 1

We excluded claims for services provided by nurse practitioners, physician assistants, and

other nonphysician practitioners. We included services covered by the fee schedule as well

as anesthesia services. We identified claims for physician services covered by the fee 

schedule by limiting the files to include only Healthcare Common Procedure Codes that are 

on the physician fee schedule and covered by Medicare. We excluded claims from 

beneficiaries in Guam, Puerto Rico, and the U.S. Virgin Islands because access issues in

these areas may be substantively different than those in the rest of the United States. 

2

We chose the month of September so our data would include two quarters of processed 

claims from April of each year. This equates to about 95 percent of the claims for services 

provided in April of each year.

3

Beneficiaries refers to all FFS Medicare beneficiaries, not just those for whom claims were 

filed. 

Page 52 GAO-06-704 Medicare Beneficiary Access
Appendix II: Methods Used to Analyze 

Medicare Claims Data 

• the total number of physician services per beneficiary who received 

services. 

We analyzed these utilization measures nationally, for urban and rural 

areas within each state, and for specific services, such as office visits for 

new and established patients. Using MSAs, we classified the nation’s 

counties as urban or rural, consolidated the urban counties and rural 

counties in each state and the District of Columbia, and created 99 

geographic areas to analyze access at a subnational level.4

 We also 

determined the number of physicians billing Medicare, whether services 

were performed by participating or nonparticipating physicians, and 

whether claims for physician services were paid either on assignment or 

not on assignment. We did not adjust the data for factors that could affect 

the provision and use of physician services, such as incidence of illness or 

coverage of new benefits. 

Medicare claims data, which are used by the Medicare program as a record 

of payments made to health care providers, are closely monitored by both

CMS and the Medicare carriers—contractors that process, review, and pay

claims for Part B-covered services. The data are subject to various internal 

controls, including checks and edits performed by the carriers before 

claims are submitted to CMS for payment approval. Although we did not 

review these internal controls, we did assess the reliability of the NCH 

data. First, we reviewed all existing information about the data, including

the data dictionary and file layouts. We also interviewed experts at CMS 

who regularly use the data for evaluation and analysis. We examined the 

data files for obvious errors, missing values, values outside of expected 

ranges, and dates outside of expected time frames. We found the data to

be sufficiently reliable for the purposes of this report. We also assessed 

the reliability of the Medicare Managed Care Market Penetration Quarterly 

State/County Data Files by examining the data for obvious errors, missing

values, and values outside of expected ranges. In addition, to further 

assess the reliability of these supplementary data, we interviewed experts 

at CMS who are responsible for the creation of these files and who 

regularly use the data for evaluation and analysis. We found these data to

be sufficiently reliable for the purposes of this report. 

Data Reliability 

 4

Rhode Island and New Jersey had no rural counties. The District of Columbia is only 

counted as an urban area. 

Page 53 GAO-06-704 Medicare Beneficiary Access
Appendix III: Specific Physician Services

Reviewed 

Using the Berenson-Eggers Type of Service (BETOS) code to which each 

procedure code in our claims data was assigned, we reviewed specific 

categories of physician services. According to the CMS, the BETOS coding 

system consists of readily understood clinical categories, is stable over 

time, and is relatively immune to minor changes in technology or practice 

patterns. Table 11 shows the specific categories we reviewed and the 

percentage change in the number of services provided per 1,000 

beneficiaries from April 2000 to April 2005. This table highlights certain 

frequently performed services and procedures. We collapsed data on other 

services and procedures into summary categories.

Table 10: Percentage Change in the Number of Services Provided per 1,000 Medicare Beneficiaries, April 2000 to April 2005 

Overall service

category Specific category 

Services per 1,000 

Medicare 

beneficiaries,

April 2000

Services per 1,000 

Medicare 

beneficiaries,

April 2005 

Percentage

change, April 2000 

to April 2005a

Evaluation and 

management (E&M) 

Office visits-new patients 26.3 27.6 5.0

Office visits-established patients 404.8 454.4 12.2

Hospital visits 170.6 209.9 23.0

Emergency room visits 31.6 36.4 15.3

Other E&M services 193.6 204.5 5.6

Imaging Advanced imaging-CAT scans 24.6 40.6 64.7

Advanced imaging-MRIs 6.5 12.7 93.5

Imaging procedures 15.8 22.7 43.7

Standard imaging 152.6 199.8 31.0

Procedures 

Major Coronary artery bypass grafts 1.1 0.8 -30.5

Aneurysm repairs 0.1 0.2 65.3

Thromboendarterectomies 0.3 0.2 -23.7

Coronary angioplasties 0.9 1.2 34.2

Pacemaker insertions 0.6 1.0 63.9

Other cardiac procedures 10.1 8.2 -18.8

Hip fracture repairs 0.5 0.4 -12.8

Hip replacements 0.3 0.4 11.1

Knee replacements 0.5 0.7 47.1

Other orthopedic procedures 1.6 2.2 35.5

Other major procedures 7.2 7.2 0.1

Appendix III: Specific Physician Services 

Reviewed 

Page 54 GAO-06-704 Medicare Beneficiary Access
Appendix III: Specific Physician Services

Reviewed 

Overall service

category Specific category

Services per 1,000 

Medicare 

beneficiaries,

April 2000

Services per 1,000 

Medicare 

beneficiaries,

April 2005 

Percentage

change, April 2000 

to April 2005a

Minor Ambulatory procedures 29.9 50.4 68.6

Corneal transplants 0.0 0.0 -17.3

Cataract removals/lens insertions 4.7 4.8 2.2

Retinal detachment repairs 0.1 0.1 8.9

Eye procedure treatments 0.8 0.9 14.0

Other eye procedures 3.2 4.5 39.3

Arthropscopies 0.5 0.8 65.1

Upper gastrointestinal endoscopies 4.3 5.2 20.6

Sigmoidoscopies 1.7 0.5 -69.0

Colonoscopies 5.1 7.1 39.7

Cystoscopies 3.2 3.6 13.6

Bronchoscopies 0.7 1.0 56.3

Laryngoscopies 1.0 1.3 38.5

Other endoscopic procedures 1.4 1.7 18.1

Dialysis services 7.7 8.1 5.9

Other minor procedures 104.0 158.4 52.3

Anesthesia 14.5 16.6 14.3

Tests Lab tests 5.4 33.8 530.4

Electrocardiograms 59.0 69.8 18.3

Stress tests 9.7 14.1 44.9

EKG monitoring 2.7 3.3 23.7

Other nonlab tests 26.9 39.0 44.7

All services 1,417.4 1,757.1 24.0

Source: GAO analysis of Medicare Part B claims and enrollment data from CMS. 

Note: Services were included if they were received in the first 28 days of April. 

a

Percentage change was calculated prior to rounding. 

Page 55 GAO-06-704 Medicare Beneficiary Access
Appendix IV: Comments from the Centers for Appendix IV Medicare & Medicaid Services : Comments from the Centers for 

Medicare & Medicaid Services 

Page 56 GAO-06-704 Medicare Beneficiary Access
Appendix IV: Comments from the Centers for 

Medicare & Medicaid Services 

Page 57 GAO-06-704 Medicare Beneficiary Access
Appendix IV: Comments from the Centers for 

Medicare & Medicaid Services 

Page 58 GAO-06-704 Medicare Beneficiary Access
Appendix IV: Comments from the Centers for 

Medicare & Medicaid Services 

Page 59 GAO-06-704 Medicare Beneficiary Access
Appendix IV: Comments from the Centers for 

Medicare & Medicaid Services 

Page 60 GAO-06-704 Medicare Beneficiary Access
Appendix V: 

A

GAO Contact and Staff 

cknowledgments 

Page 61 GAO-06-704

Appendix V: GAO Contact and Staff 

Acknowledgments 

GAO Contact A. Bruce Steinwald (202) 512-7101 or steinwalda@gao.gov

James Cosgrove, Assistant Director; Kevin Dietz; Jessica Farb; Hannah 

Fein; Zachary Gaumer; Rich Lipinski; Jennifer M. Rellick; Dan Ries; and 

Eric Wedum made key contributions to this report. 

Medicare Beneficiary Access

Acknowledgments 

(290412) 
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