GAO 

United States Government Accountability Office

Report to the Committee on Finance, 

U.S. Senate 

MEDICARE 

PHYSICIAN 

SERVICES 

Utilization Trends 

Indicate Sustained 

Beneficiary Access 

with High and 

Growing Levels of 

Service in Some Areas 

of the Nation 

August 2009 

GAO-09-559 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

August 2009

MEDICARE PHYSICIAN SERVICES 

Utilization Trends Indicate Sustained Beneficiary 

Access with High and Growing Levels of Service in 

Highlights of GAO-09-559, a report to the Some Areas of the Nation 

Committee on Finance, U.S. Senate 

Congress, policy analysts, and 

groups representing physicians 

have raised questions about 

beneficiary access to Medicare 

physician services. At the same 

time, high levels of spending for 

health care in some parts of the 

country, and rapid increases in 

spending for physician services, 

have been identified as factors that 

threaten the long-term fiscal 

sustainability of the Medicare 

program. 

GAO was asked to assess 

beneficiary access to physician 

services and to identify indicators 

of potential overutilization of 

physician services. In this report, 

GAO (1) examines whether, from 

2000 through 2008, beneficiaries 

had problems accessing physician 

services; (2) identifies areas of the 

country in which Medicare 

beneficiaries are potentially 

overserved by physicians; and 

(3) describes characteristics that 

distinguish the potentially 

overserved areas from other areas 

in the nation. 

GAO analyzed the most recent data 

available from several sources, 

including an annual Centers for 

Medicare & Medicaid Services 

(CMS) survey of fee-for-service 

(FFS) Medicare beneficiaries, 

Medicare physician claims for 

services provided in April of each 

year from 2000 through 2008, the 

Health Resources and Services 

Administration’s Area Resource 

File, and the U.S. Census Bureau. 

GAO found that Medicare beneficiaries experienced few problems accessing 

physician services during its period of study. Very small percentages of 

Medicare beneficiaries—less than 3 percent—reported major difficulties 

accessing physician services in 2007 and 2008. The proportion of beneficiaries 

who received physician services and the number of services per beneficiary 

served increased nationwide from April 2000 to April 2008. (See figure.) 

Indicators of physician willingness to serve Medicare beneficiaries and to 

accept Medicare fees as payments in full also rose from 2000 to 2008. 

Potentially overserved areas—areas that were in the top half in both the level 

and growth in utilization of physician services—tend to be in the more densely 

populated urban regions and the eastern part of the United States. Large 

metropolitan areas were much more likely to be potentially overserved than 

rural and small metropolitan areas. Areas east of the Mississippi River were 

also more likely to be potentially overserved than those in the west. 

Potentially overserved and other areas are similar in demographic 

characteristics and the capacity to provide health care services. The two 

groups are also similar in Medicare beneficiary satisfaction with health care. 

In contrast, certain types of physician services, such as advanced imaging and 

minor procedures, are performed more frequently in potentially overserved 

areas relative to other areas, suggesting differences in physician practice 

patterns. 

In commenting on a draft of this report, CMS noted the agency’s longstanding 

practice of monitoring the effect of policy changes on beneficiary access to 

Medicare services, and stated that this report would help in that effort. 

Trends in Utilization of Physician Services

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

Percentage

30

40

50

60

2000

2001

2002

2003

2004

2005

2006

2007

2008

0

2,500

3,000

3,500

4,000

2000

2001

2002

2003

2004

2005

2006

2007

2008

Services per 1,000 beneficiaries served

Percentage of Medicare FFS beneficiaries 

receiving physcian services in

April, 2000-2008

Number of physician services provided per 

1,000 Medicare FFS beneficiaries served in 

April, 2000-2008

View GAO-09-559 or key components.

For more information, contact A. Bruce 

Steinwald at (202) 512-7114 or 

steinwalda@gao.gov. 
Page i GAO-09-559 

Contents 

Letter 1

Background 7 

Indicators Show Few Problems in Beneficiary Access to Physician 

Services 12 

Potentially Overserved Areas Tend to Be in More Densely 

Populated Urban Regions and the Eastern Part of the Country 23 

Potentially Overserved Areas Are Largely Similar to Other Areas, 

with the Exception of Physician Practice Patterns 26 

Concluding Observations 35 

Agency and Industry Comments and Our Evaluation 35 

Appendix I Scope and Methodology 37 

Appendix II Average Utilization Values by Geographic 

Area Type 45 

Appendix III Utilization Status of Geographic Areas 46 

Appendix IV Selected Physician Services in Potentially 

Overserved and Other Areas 60 

Appendix V Utilization Status of Medicare Physician 

Payment Localities 62 

Appendix VI Selected Physician Services in Potentially 

Overserved and Other Medicare Physician 

Payment Localities 67 

Appendix VII Utilization Status of Hospital Referral Regions 69 

 Medicare Physician Services 
Appendix VIII Selected Physician Services in Potentially 

Overserved and Other HRRs 79 

Appendix IX Comments from the Centers for Medicare & 

Medicaid Services 81 

Appendix X GAO Contact and Staff Acknowledgments 84 

Tables 

Table 1: Medicare Beneficiaries Who Reported Major Difficulties 

Accessing Physician Services, 2007-2008 13 

Table 2: Distribution of Utilization Status by Type of Geographic 

Area 23 

Table 3: Selected Demographic Characteristics in Potentially 

Overserved and Other Areas 28 

Table 4: Selected Health Care Capacity Characteristics in 

Potentially Overserved and Other Areas 29 

Table 5: Selected Medicare Beneficiary Satisfaction Indicators in 

Potentially Overserved and Other Areas, 2008 31 

Table 6: Selected Physician Service Categories per 1,000 Medicare 

FFS Beneficiaries in Potentially Overserved and Other 

Areas, 2008 32 

Table 7: Selected Physician Services per 1,000 Medicare FFS 

Beneficiaries in Potentially Overserved and Other Areas, 

2008 34 

Table 8: Selected CAHPS Survey Questions Related to Beneficiary 

Access to Physician Services, 2008 38 

Table 9: Geographic Area Types for Utilization Analysis 41 

Table 10: Distribution of Geographic Areas by Ranking 42 

Table 11: Average Utilization by Geographic Area Type 45 

Table 12: Utilization Status of Geographic Areas 47 

Table 13: Selected Physician Services Provided per 1,000 Medicare 

FFS Beneficiaries in Potentially Overserved Areas and 

Other Areas 61 

Table 14: Utilization Status of Medicare Physician Payment 

Localities 63 

Page ii GAO-09-559 Medicare Physician Services
Table 15: Selected Physician Services Provided per 1,000 Medicare 

FFS Beneficiaries in Potentially Overserved and Other 

Medicare Physician Payment Localities 68 

Table 16: Utilization Status of Hospital Referral Regions 70 

Table 17: Selected Physician Services Provided per 1,000 Medicare 

FFS Beneficiaries in Potentially Overserved and Other 

Hospital Referral Regions 80 

Figures 

Figure 1: Percentage of Medicare Beneficiaries Receiving Physician 

Services in April, 2000-2008 14 

Figure 2: Change from 2000 to 2008 in Proportion of Medicare 

Beneficiaries Receiving Physician Services in April, by 

State Urban and Rural Areas 15 

Figure 3: Number of Physician Services Provided per 1,000 

Medicare Beneficiaries Served in April, 2000-2008 16 

Figure 4: Change from 2000 to 2008 in Number of Physician 

Services Provided per 1,000 Medicare Beneficiaries 

Served in April, by State Urban and Rural Areas 18 

Figure 5: Numbers of Emergency Room Visits, Office Visits for 

New Patients, and Office Visits for Established Patients 

per 1,000 FFS Medicare Beneficiaries in April, 2000-2008 20 

Figure 6: Number of Physicians Billing Medicare for Services 

Provided to Medicare Beneficiaries in April and Number 

of Medicare FFS Beneficiaries, 2000-2007 21 

Figure 7: Proportion of Physician Services by Medicare 

Participation and Assignment Status 22 

Figure 8: Geographic Areas by Type of Area and Utilization Status 25 

Page iii GAO-09-559 Medicare Physician Services
Abbreviations 

AMA American Medical Association 

ARF Area Resource File 

BETOS Berenson-Eggers Type of Service 

CAHPS Consumer Assessment of Healthcare Providers and 

 Systems 

CBO Congressional Budget Office 

CMS Centers for Medicare & Medicaid Services 

CT computed tomography 

EKG electrocardiogram 

FFS fee-for-service 

HRR hospital referral region 

HRSA Health Resources and Services Administration 

HSC Center for Studying Health System Change 

MedPAC Medicare Payment Advisory Commission 

MEI Medicare Economic Index 

MRI magnetic resonance imaging 

MSA metropolitan statistical area 

NCH National Claims History 

OMB Office of Management and Budget 

SGR sustainable growth rate 

UPIN unique physician identification number 

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Page iv GAO-09-559 Medicare Physician Services
Page 1 GAO-09-559 

 

United States Government Accountability Office

Washington, DC 20548 

 

August 28, 2009 

The Honorable Max Baucus 

Chairman 

The Honorable Charles E. Grassley 

Ranking Member 

Committee on Finance 

United States Senate 

Over the last several years, rapid spending growth in Medicare Part B 

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

concerns regarding the Medicare program’s fiscal sustainability.1

According to the Medicare Trustees, despite statutory controls on 

physician fee increases, spending for physician services has steadily 

increased from about $32 billion in 1998 to about $61 billion in 2008.2

Medicare fee-for-service (FFS) pays for more than 7,000 physician services 

through an annually updated fee schedule. Since the early 1990s, Congress, 

policy analysts, and groups representing physicians have periodically 

questioned whether efforts to control spending by limiting increases in 

physician fees could undermine beneficiary access to physician services. 

The Medicare physician fee schedule is updated annually by the 

sustainable growth rate (SGR) system, with the intent of limiting the total 

growth in Medicare spending for physician services over time. Since the 

SGR’s establishment, annual updates to physician fees have varied and 

produced a 4.8 percent reduction in physician fees in 2002. Congressional 

and administrative actions averted subsequent reductions in physician fees 

for 2003 through 2009. However, concerns about access remained as the 

fee updates during this period did not keep pace with the growth in 

1

Medicare is the federally financed health insurance program for persons aged 65 and over, 

certain individuals with disabilities, and individuals with end-stage renal disease. Eligible 

individuals are automatically covered by Medicare Part A, which covers hospital and other 

inpatient stays. Medicare Part B is optional insurance and covers hospital outpatient, 

physician, and other services. Medicare Parts A and B are known as traditional Medicare or 

Medicare fee-for-service. 

2

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

Medical Insurance Trust Funds, 2009 Annual Report of the Boards of Trustees of the 

Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds 

(Washington, D.C., May 12, 2009), and 2008 Annual Report of the Boards of Trustees of the 

Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds 

(Washington, D.C., Mar. 25, 2008). 

 Medicare Physician Services 
 

Medicare’s estimated cost to physicians for providing their services. Under 

current law, Medicare’s fees to physicians are projected to be reduced by 

about 21 percent in January 2010.3

 Although these fee reductions may not 

occur if Congress intervenes, the uncertainty surrounding physicians’ 

Medicare fees points to the ongoing need to monitor beneficiary access to 

physician services. 

Our previous work has shown that this uncertainty about physician fees 

has not been accompanied by reduced beneficiary access to physician 

services, as measured by changes in FFS beneficiary utilization of these 

services. In 2005, we reported that utilization of Medicare physician 

services increased from 2000 to 2002 and that the 2002 reduction in 

physician fees did not appear to have an impact on beneficiary access.4

 In 

a 2006 report, we found no evidence of a decrease in access from 2000 to 

2005, as measured in terms of utilization; our findings suggested that 

beneficiary access actually increased.5

 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 as well. 

Although these increases in utilization demonstrated that beneficiaries 

were able to access physician services, our previous work did not 

determine whether all of the increases in utilization we found were 

appropriate. Wide geographic variation in Medicare spending for physician 

services—unrelated to beneficiary health status or outcomes—indicates 

that in some areas of the country, health needs alone may not always 

determine the level of utilization of, and therefore the amount of spending 

 

3

The Medicare Improvements for Patients and Providers Act of 2008 canceled a 

10.6 percent reduction in Medicare’s payments for physician services that was scheduled to 

go into effect on July 1, 2008. Pub. L. No. 110-275, § 131,122 Stat. 2494, 2520. The act froze 

physician payment rates for the remainder of 2008 and increased them by 1.1 percent in 

January 2009. The Congressional Budget Office estimated that when payment rates are 

again determined by the SGR in 2010, Medicare payments for physician services will be 

reduced by 21 percent. Congressional Budget Office Cost Estimate, H.R. 6331 Medicare 

Improvements for Patients and Providers Act of 2008 (Washington, D.C., July 23, 2008). 

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

GAO, Medicare Physician Services: Use of Services Increasing Nationwide and 

Relatively Few Beneficiaries Report Major Access Problems, GAO-06-704 (Washington, 

D.C.: July 21, 2006). 

Page 2 GAO-09-559 Medicare Physician Services
 

on, physician services.6 These areas may be potentially overserved 

compared to other areas of the nation. Some studies have shown that the 

provision of more care does not necessarily mean better health care or 

better health outcomes for patients and in some cases may lead to harm.7

Therefore, some of the increased utilization of physician services that we 

identified in previous studies may not have been warranted. 

You raised questions about Medicare beneficiary access to physician 

services, as well as questions about long-term fiscal challenges for and 

inefficiency in Medicare. To obtain more information on these topics, you 

asked us to provide an assessment of beneficiary access to physician 

services and also to identify indicators of potential beneficiary 

overutilization of physician services. This report (1) examines whether, 

from 2000 through 2008, beneficiaries had problems accessing physician 

services; (2) identifies areas of the country in which Medicare 

beneficiaries are potentially overserved by physicians; and (3) describes 

characteristics that distinguish the potentially overserved areas from other 

areas in the nation. 

To address the first objective, we constructed three types of indicators to 

measure beneficiary access to physician services: beneficiary perceptions 

about access, utilization of physician services, and indicators of physician 

willingness to participate in Medicare and serve Medicare beneficiaries. 

Beneficiary perceptions about access were obtained from an analysis of 

the Consumer Assessment of Healthcare Providers and Systems (CAHPS) 

survey data from 2007 and 2008. CAHPS is an annual Centers for Medicare 

& Medicaid Services (CMS) patient satisfaction survey of Medicare 

beneficiaries.8

 Specifically, we examined beneficiary responses to two 

 

6

Elliott 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, and Elliott 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. 

7

Fisher et al., “The Implications of Regional Variations in Medicare Spending. Part 1: The 

Content, Quality, and Accessibility of Care”; Fisher et al., “The Implications of Regional 

Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care”; 

Elliott 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; and Joseph P. Newhouse and The Insurance 

Experiment Group, Free for All? Lessons from the RAND Health Insurance Experiment 

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

8

We used only CAHPS survey data from Medicare FFS beneficiaries. 

Page 3 GAO-09-559 Medicare Physician Services
 

questions related to access to physician services. The survey questions 

asked how often an appointment for routine care was available as soon as 

the respondent thought necessary and how often it was easy to obtain an 

appointment with a specialist; our analysis was limited to beneficiaries 

who needed such appointments. The possible responses were “never,” 

“sometimes,” “usually,” and “always.” We considered respondents to have 

reported a major access problem when they responded “never” to one of 

the two survey questions. We analyzed utilization trends by examining all 

Medicare claims for physician services provided in the first 28 days of each 

April from 2000 through 2008.9,10,11 Specifically, we calculated two 

measures of utilization—the proportion of FFS beneficiaries receiving 

physician services and the number of services per 1,000 beneficiaries who

received services. We examined these trends in both urban and rur

nationwide and in individual states.

al areas 

 

12 We also examined trends in 

utilization of specific services, such as physician office visits, from 2000 

through 2008. We further utilized claims data to analyze trends in the 

number of physicians billing Medicare and in the proportion of services for 

which Medicare fees were accepted as payment in full. (For more 

information on our scope and methodology, see app. I.) 

9

We examined over 60 million claims for the first 28 days of April of each year. These 

claims represent an annual snapshot of beneficiary access to physician services for each of 

the 9 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 beginning January 1, 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. 

10We 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. 

11We excluded beneficiaries in Guam, Puerto Rico, and the U.S. Virgin Islands. 

12Using 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 4 GAO-09-559 Medicare Physician Services
 

To address our second objective, we identified areas of the country where 

utilization of physician services in Medicare is potentially excessive. 

Because policymakers have expressed concerns about both the level and 

growth of services in the Medicare program, we incorporated both factors 

in our measure of potential overservice.13 Specifically, we identified areas 

that were both relatively high in their level of utilization and relatively high 

in their growth in utilization. Using U.S. Census Bureau14 and Office of 

Management and Budget (OMB) classifications, we classified counties into 

one of four types of geographic areas: metropolitan divisions, large 

metropolitan statistical areas (MSA), small MSA areas, and rural areas.15

Metropolitan divisions and large MSAs (MSAs with at least 200,000 

residents) each constituted a separate geographic area. We combined 

smaller MSAs with other small MSAs within each state. We designated 

counties outside of metropolitan divisions and MSAs as rural and 

combined these rural areas within each state. This classification process 

yielded 296 areas across the United States. To determine utilization status, 

we measured utilization in each of these areas by examining the number of 

services per beneficiary who received services in April 2000 and April 

2008. We ranked the areas by their level of utilization in 2000 and the 

change in utilization from 2000 to 2008. We then designated areas in the 

 

13U.S. Senator Max Baucus, Call to Action: Health Care Reform 2009 (Washington, D.C., 

Nov. 12, 2008), and Congressional Budget Office, Factors Underlying the Growth in 

Medicare’s Spending for Physician Services (Washington, D.C., June 2007). 

14We referenced counties to metropolitan statistical areas and metropolitan divisions using 

U.S. Census Bureau data from the Missouri Census Data Center. 

15We excluded four counties with low populations because they lacked data on Medicare 

enrollment or utilization of physician services. 

Page 5 GAO-09-559 Medicare Physician Services
 

top half of both measures as “potentially overserved” areas and the rest of 

the areas as “other” areas (for more information on the rank of each area, 

see app. III).16,17

To address the third objective, we reviewed literature to identify and 

construct area-level characteristics that could drive the use of physician 

services.18 We then compared potentially overserved and other areas based 

on these characteristics. Specifically, we examined demographic 

characteristics and the capacity to provide health care services. We also 

compared beneficiary satisfaction with their health care in the two groups 

of areas, as measured by a beneficiary survey, and the types of physician 

services provided in the two types of areas. To make these comparisons, 

we obtained the most recent available data on demographic and health 

care utilization capacity characteristics from the Area Resource File 

(ARF), a national county-level health resource information database 

produced by the Health Resources and Services Administration (HRSA) of 

the Department of Health and Human Services; population and income 

data from the U.S. Census Bureau; data on beneficiary experiences from 

the 2008 CAHPS survey; and utilization data from Medicare physician 

claims from April 2008.19 We also analyzed and compared utilization of 

 

16By labeling areas as “potentially overserved” and “other,” we do not suggest that the level 

of care in the other areas is uniformly appropriate. For example, the level of services 

provided in the Los Angeles-Long Beach-Glendale metropolitan division (see table 12 in 

app. III) was among the highest in the nation in both 2000 and 2008. However, because the 

growth rate was below average in this area, it did not meet our criteria for being placed in 

the potentially overserved category. 

17In addition, we analyzed the number of services per beneficiary who received services in 

April 2000 and April 2008 in Medicare’s 87 physician payment localities and in the 306 

hospital referral regions as defined by the Dartmouth Atlas Project. We ranked the two area 

types by their level of utilization in 2000 and the change in utilization from 2000 to 2008. We 

then designated Medicare physician payment localities and hospital referral regions in the 

top half of both measures as “potentially overserved” and the rest of the Medicare 

physician payment localities and hospital referral regions as “other.” For more information 

on the rank of each Medicare physician payment locality, see app. V, and for more 

information on the rank of each hospital referral region, see app. VII. 

18We were not able to construct variables to exhaustively examine all of the potential 

drivers of health care utilization. For example, we were not able to construct a variable to 

measure the prevalence of coordinated care in an area using either data on managed care 

penetration or the number of physician group practices in an area. 

19To account for different levels of urbanization between potentially overserved and other 

areas, we adjusted the other areas group to reflect the same urban/rural composition as the 

potentially overserved group. 

Page 6 GAO-09-559 Medicare Physician Services
 

specific types of physician services in potentially overserved and other 

areas (see app. IV for more information).20

We took several steps to measure the reliability of data used in this report. 

For the CAHPS and Medicare claims data, we reviewed the documentation 

for both data sets, examined the accuracy and completeness of the data, 

and interviewed experts to ensure that we were using the data 

appropriately. The utilization information in claims data is generally 

considered reliable, as the data are used by the Medicare program to 

determine payment to health care providers and are closely monitored by 

CMS and Medicare carriers. We also examined the reliability of the U.S. 

Census Bureau and ARF data by reviewing documentation and checking 

for obvious errors in the data sets. We found all four data sources 

sufficiently reliable for this report. 

We conducted this performance audit from May 2008 through August 2009 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives. 

Since 1992, the Medicare program has used a resource-based fee schedule 

to pay for physician services in the traditional FFS Medicare program. The 

physician fee schedule includes three components: the relative value for 

the service, a geographic adjustment, and a conversion factor. The relative 

value for a service compares the resources involved in performing one 

service with those of other services. There are more than 7,000 physician 

services in the fee schedule and each one is assigned a relative value. The 

geographic adjustment was designed to ensure that fees appropriately 

Background 

 

20In addition, we analyzed the utilization of specific services in April 2008 in potentially 

overserved and other Medicare physician payment localities and in potentially overserved 

and other hospital referral regions as defined by the Dartmouth Atlas Project. For more 

information on the difference in utilization of these services between potentially 

overserved and other Medicare physician payment localities, see app. VI, and for more 

information on the difference in utilization of these services between potentially 

overserved and other hospital referral regions, see app. VIII. 

Page 7 GAO-09-559 Medicare Physician Services
 

reflect the geographic variation in costs associated with operating a 

medical practice. Finally, the fee schedule uses a conversion factor 

expressed in dollars to determine the payment rate for a particular 

physician service.21 The conversion factor is updated annually based on 

the SGR formula, which is set by law. The SGR is a spending target system 

designed to control growth in spending attributable to increases in the 

number of services, known as volume, and to the services’ complexity and 

costliness, known as intensity. Although the SGR formula has called for 

negative physician fee updates in recent years, Congress has mandated 

either no change or a positive update that has been less than growth in the 

estimated cost to physicians for providing their services.22 Beginning in 

2010, physician fees are projected to be reduced by 21 percent, according 

to the Congressional Budget Office (CBO). 

Medicare generally pays physicians a predetermined amount for each 

service provided. Physicians who “accept assignment” are those who agree 

to accept Medicare’s fee as payment in full. The fee includes the 

coinsurance amount (usually 20 percent) paid by the beneficiary. 

Physicians who sign Medicare participation agreements—referred to as 

participating physicians—must accept assignment for all Medicarecovered services that 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 

Medicare-approved amount is also reduced by 5 percent, but the physician 

may collect from beneficiaries a portion of the difference between his or 

 

21There is a separate anesthesia services conversion factor that is updated each year. 

22The 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. 

Page 8 GAO-09-559 Medicare Physician Services
 

her charge and the Medicare-approved amount—a practice known as 

balance billing.23,24

Access to Physician 

Services 

Several recent surveys of Medicare beneficiary access to physician 

services have not identified major access issues. For example, a 2008 

Medicare Payment Advisory Commission (MedPAC) survey,25 a 2007 

Center for Studying Health System Change (HSC) survey, a 2007 

Commonwealth Fund survey, and a 2007 AARP survey all concluded that 

Medicare beneficiaries had few problems obtaining physician services.26

MedPAC found that most beneficiaries were able to schedule timely 

routine appointments and find a new physician when needed. Additionally, 

Medicare beneficiaries reported similar or better access to physician 

services compared to individuals covered by private insurance, according 

to MedPAC, HSC, Commonwealth Fund, and AARP surveys. Both the 

Commonwealth Fund and AARP also found that Medicare beneficiaries 

are more likely than those with private insurance to report high levels of 

satisfaction with their health care and access to physicians. 

 

23Specifically, nonparticipating physicians who do not accept assignment can charge up to 

15 percent above the reduced Medicare-approved amount and thus receive approximately 

109 percent of the Medicare-approved fee for that service—this amount is known as the 

limiting charge. The beneficiary typically has to pay the nonparticipating physician the full 

amount of the limiting charge, and Medicare reimburses the beneficiary for 80 percent of 

the reduced Medicare-approved amount. 

24Physicians may “opt out” of the Medicare program altogether and charge any amount for 

the services they provide, but they must inform beneficiaries 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. Since 1998, 

relatively few physicians—approximately 8,300 at the end of 2008—have opted out of the 

Medicare program. 

25MedPAC was established by the Balanced Budget Act of 1997, Pub. L. No. 105-33 § 4022, 

111 Stat. 251, 350, 42 U.S.C. § 1395b-6 (2000), to advise Congress on issues affecting the 

Medicare program. 

26Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment 

Policy (Washington, D.C., March 2009); Center for Studying Health System Change as cited 

by MedPAC; Karen Davis, et al., “Meeting Enrollees’ Needs: How Do Medicare and 

Employer Coverage Stack Up?” Health Affairs, vol. 28, no. 4 (published online May 12, 

2009); and AARP, Access to Physicians Survey (Washington: D.C., February 2007). 

Page 9 GAO-09-559 Medicare Physician Services
 

Physician spending under the Medicare program has historically grown at 

a rapid pace, at times reaching double-digit increases, but these increases 

may not mean better health care or better outcomes for beneficiaries. 

Specifically, some of the higher volume and intensity that drive spending 

growth may not be medically necessary. Physicians have a financial 

incentive to perform as many services as possible because Medicare pays 

them a fee for each service provided, with little accountability for quality 

or efficiency. The Senate Finance Committee has stated that the 

combination of high health care spending and lagging quality is 

unsustainable for both the government and patients.27

Geographic Variation in 

the Utilization of Physician 

Services 

Several studies of geographic variation in Medicare spending have 

concluded that some utilization may not be warranted. A February 2008 

CBO report found that per capita Medicare spending varied substantially 

among states, ranging in 2004 from $4,000 in Utah to $6,700 in 

Massachusetts.28 CBO found that the price paid for health care services 

and severity of illness were important factors, but cited research 

indicating that these two factors together likely account for less than half 

of the geographic variation in spending. CBO also found that patient 

preferences and income appear to explain little of the variation and 

concluded that some variation in medical practice may be attributable to 

differences in the supply of medical resources, such as specialist 

physicians. 

Several studies from Dartmouth have found that Medicare beneficiaries 

living in areas with high levels of health care spending and utilization do 

not experience better health outcomes or quality of care. One Dartmouth 

study noted that Medicare spending would fall by 29 percent if spending 

levels in the lowest decile of areas were realized in all higher spending 

regions.29 Dartmouth researchers concluded that geographic variation in 

Medicare spending can be attributed to how physicians respond to 

 

27U.S. Senate, Committee on Finance, Transforming the Health Care Delivery System: 

Proposals to Improve Patient Care and Reduce Health Care Costs (Washington, D.C., 

Apr. 29, 2009), http://www.finance.senate.gov/sitepages/leg/LEG%202009/042809%20 

Health%20Care%20Description%20of%20Policy%20Option.pdf (accessed June 3, 2009). 

28Congressional Budget Office, Geographic Variation in Health Care Spending 

(Washington, D.C., February 2008). 

29John E. Wennberg et al., “Geography and the Debate Over Medicare Reform,” Health 

Affairs, Web exclusive (Feb. 13, 2002): W96-W114. 

Page 10 GAO-09-559 Medicare Physician Services
 

technology, capital, and other resources under FFS.30 For example, 

physicians in higher-spending regions were more likely than those in 

lower-spending regions to recommend discretionary services and more 

resource-intensive services.31 Clinical decisions are associated with 

physician discretion when the evidence does not point clearly to a correct 

action in a specific clinical situation. In a review of 2,500 treatments for a 

variety of medical conditions, more than half were subject to physician 

discretion.32

Congress has recently shown an interest in varying annual Medicare 

physician payment updates by geographic area. In the Deficit Reduction 

Act of 2005, Congress directed MedPAC to examine alternatives to the 

current payment system, including options that varied payment updates by 

geographic areas.33 In a 2007 study, MedPAC found that setting fee update 

amounts by geographic area would recognize that practice patterns differ 

regionally and therefore have different contributions to overall growth in 

volume and spending.34 MedPAC suggested that regional updates would 

improve equity across the nation and could help reduce geographic 

variation over time. Congress has also held hearings on revising the 

method used to update physician payments, and the Chairman of the 

Senate Finance Committee has stated that reforming physician payment is 

an important component of health care reform.35

 

30Elliott S. Fisher et al., “Slowing the Growth of Health Care Costs—Lessons from Regional 

Variation,” New England Journal of Medicine, vol. 360, no. 9 (2009): 849-852. 

31B. Sirovich, et al., “Discretionary Decision Making by Primary Care Physicians and the 

Cost of U.S. Health Care,” Health Affairs, vol. 27, no. 3 (2008): 813-23. Using a survey of 

about 800 primary care physicians, this study found that compared with those in areas with 

the lowest quintile of spending, physicians practicing in areas with the highest quintile of 

spending would recommend the following additional services each year per 100 patients in 

each clinical category: 80 hypertension follow-up visits, 14 spiral computed tomography 

scans, 25 echocardiograms, 24 cardiac care unit admissions, and 29 gastroenterology 

referrals. 

32“How Much Do We Know?” BMJ Clinical Evidence, http://clinicalevidence.bmj.com/ 

ceweb/about/knowledge.jsp (accessed Apr. 24, 2009). 

33Pub. L. No. 109-171, § 5104(c), 120 Stat. 4, 40 (2006). 

34Medicare Payment Advisory Commission, Report to the Congress: Assessing Alternatives 

to the Sustainable Growth Rate System (Washington, D.C., March 2007). 

35Baucus, Reforming America’s Health Care System: A Call to Action. 

Page 11 GAO-09-559 Medicare Physician Services
 

Indicators Show Few 

Problems in 

Beneficiary Access to 

Physician Services 

Together, the three types of indicators we reviewed show that Medicare 

beneficiaries experienced few problems accessing physician services. 

Small percentages of Medicare beneficiaries reported never easily 

obtaining appointments; measures of beneficiaries receiving physician 

services increased nationwide from 2000 to 2008; and indicators of 

physician willingness to serve Medicare beneficiaries and to accept 

Medicare fees as payment in full also increased from 2000 to 2008. 

Few Beneficiaries 

Reported Major Access 

Problems in 2007 and 2008 

Few Medicare beneficiaries reported major difficulties accessing physician 

services in 2007 and 2008. (See table 1.) Specifically, among those who 

needed routine care, very small percentages of beneficiaries reported that 

it was never easy to schedule an appointment as soon as they felt they 

needed it—2.5 percent in 2007 and 2.4 percent in 2008. Similarly, in both 

2007 and 2008, 2.1 percent of beneficiaries who needed to see a specialist 

reported that it was never easy to get appointments with specialists when 

needed. Nationwide, the percentages of beneficiaries who reported major 

difficulties accessing routine or specialist care were the same for those 

living in urban areas and in rural areas in 2008—2.4 percent for routine 

care and 2.1 percent for specialist care. Within every state and the District 

of Columbia, less than 5 percent of the beneficiaries reported major 

difficulties accessing physician services in 2008. For example, the 

proportion of beneficiaries who reported never being able to easily 

schedule an appointment with a specialist in 2008 ranged from 0.3 percent 

in North Dakota to 4.7 percent in New Mexico. The proportion of 

beneficiaries who reported it was never easy to promptly schedule an 

appointment for routine care ranged from 1.5 percent in Oregon to 

4.0 percent in Alaska. 

Page 12 GAO-09-559 Medicare Physician Services
 

Table 1: Medicare Beneficiaries Who Reported Major Difficulties Accessing 

Physician Services, 2007-2008 

Percentage of 

respondents who 

reported having 

major difficulties 

CAHPS survey questions regarding 

access to physician services 2007 2008

In the last 6 months, not counting the times you needed care right 

away, how often did you get an appointment for your health care 

at a doctor’s office or clinic as soon as you thought you needed? 2.5 2.4

In the last 6 months, how often was it easy to get appointments 

with specialists? 2.1 2.1

Source: GAO analysis of Medicare CAHPS surveys from CMS. 

Notes: We defined major difficulties as reporting “never” being able to schedule an appointment for 

routine care or with a specialist in the past 6 months. The total number of individuals responding to 

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

stated a need to schedule an appointment for routine care or see a specialist. 

Proportion of Beneficiaries 

Receiving Physician 

Services Increased from 

2000 to 2008 

In general, the proportion of beneficiaries who received physician services 

rose during the period covered by our review. (See fig. 1.) Specifically, 

from 2000 to 2008, the proportion of beneficiaries receiving services 

during the month of April rose from about 46 percent to about 50 percent. 

Although the proportion of beneficiaries receiving physician services 

increased from 2000 to 2008, the rate of increase was not constant. The 

measure declined slightly in April 2003, but the proportion of beneficiaries 

receiving services remained about one percentage point higher than in 

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

measure increased in both urban and rural areas.36 Specifically, the 

proportion of beneficiaries receiving services rose from about 47 percent 

in April 2000 to about 51 percent in April 2008 in urban areas and from 

about 42 percent in April 2000 to about 45 percent in April 2008 in rural 

areas. 

 

36Using OMB’s system for defining MSAs, 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, creating 99 geographic areas. There were 51 urban areas and 48 rural areas. 

There were no rural areas in New Jersey, Rhode Island, and the District of Columbia. 

Page 13 GAO-09-559 Medicare Physician Services
 

Figure 1: Percentage of Medicare Beneficiaries Receiving Physician Services in April, 2000-2008 

Percentage

0

10

20

30

40

50

60

2008

200

2000

2001

2002

2003

2004

2005

2006

2007

8

200

2000

2001

2002

2003

2004

2005

2006

2007

8

2000

2001

2002

2003

2004

2005

2006

2007

Total

Urban

Rural

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

45.5

49.7

46.7

51.3

45.4

42.2

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

and their claim was processed by the end of the third quarter of each calendar year. 

From 2000 through 2008, the proportions of beneficiaries receiving 

services in April varied by state urban and rural areas. For example, in 

April 2000, the proportion of beneficiaries served ranged from 28.4 percent 

in rural Alaska to 51.8 percent in urban Pennsylvania. In April 2008, the 

proportion of beneficiaries served ranged from 32.7 percent in rural Alaska 

to 57.5 percent in urban Florida. 

Within 88 of the 99 urban and rural areas we examined, the proportion of 

beneficiaries receiving services increased from April 2000 to April 2008. 

(See fig. 2.) The largest increase in the percentage of beneficiaries 

receiving services was 7.9 percentage points in rural Maryland. There was 

a slight decline—less than 1 percentage point—in six areas: rural 

California, rural Colorado, rural Idaho, urban Maine, rural Montana, and 

rural Oregon. The largest decline in the proportion of beneficiaries 

served—about 2 percentage points—occurred in rural New Hampshire 

and rural Hawaii. 

Page 14 GAO-09-559 Medicare Physician Services
 

Figure 2: Change from 2000 to 2008 in Proportion of Medicare Beneficiaries Receiving Physician Services in April, by State 

Urban and Rural Areas 

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

Urban areas within states

-2.02 to -0.01 percentage point change

0.00 to 1.99 percentage point change

2.00 to 3.99 percentage point change

4.00 to 7.93 percentage point change

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

and their claim was processed by the end of the third quarter of each calendar year. There were no 

rural areas in New Jersey, Rhode Island, and the District of Columbia. 

Page 15 GAO-09-559 Medicare Physician Services
 

Average Number of 

Physician Services 

Provided per Beneficiary 

Rose from 2000 to 2008 

From April 2000 to April 2008, an increasing number of services were 

provided to beneficiaries who were treated by a physician. (See fig. 3.) 

Specifically, in that period, the average number of services provided per 

1,000 beneficiaries who were treated increased by about 15 percent—from 

about 3,400 to about 3,900. From April 2000 through April 2008, the 

number of services provided per 1,000 beneficiaries who were treated was 

lower in rural areas relative to urban areas. However, in percentage terms, 

the urban and rural areas experienced similar increases in the number of 

services per 1,000 treated beneficiaries—about a 17 percent increase in 

urban areas (from about 3,500 in April 2000 to about 4,100 in April 2008) 

and about a 13 percent increase in rural areas (from about 3,200 in April 

2000 to about 3,600 in April 2008). 

Figure 3: Number of Physician Services Provided per 1,000 Medicare Beneficiaries Served in April, 2000-2008 

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

2008

200

2000

2001

2002

2003

2004

2005

2006

2007

8

200

2000

2001

2002

2003

2004

2005

2006

2007

8

2000

2001

2002

2003

2004

2005

2006

2007

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

Services per 1,000 beneficiaries served

3,430

3,944

3,514

4,054

3,194

3,602

Total

Urban

Rural

Note: Beneficiaries and services were included in the count if the service was received in the first 28 

days of April and the claim was processed by the end of the third quarter of each calendar year. 

Page 16 GAO-09-559 Medicare Physician Services
 

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

and rural areas. For example, in April 2000, the number of services per 

1,000 beneficiaries served ranged from about 2,800 in rural Utah to about 

3,900 in urban Texas. In April 2008, the number of services per 1,000 

beneficiaries served ranged from about 3,100 in rural Hawaii to about 

4,500 in urban Florida. 

Within every state’s urban and rural areas, there was an increase from 

April 2000 to April 2008 in the average number of services provided for 

each beneficiary who was treated by a physician. (See fig. 4.) In 59 of the 

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

beneficiaries increased by about 12 percent or more. Among the 51 urban 

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

provided per 1,000 beneficiaries ranged from about 5 percent in Vermont 

to about 24 percent in New York. Among the 48 rural areas, the increase 

ranged from about 1 percent in Alaska to about 23 percent in Connecticut. 

Page 17 GAO-09-559 Medicare Physician Services
 

Figure 4: Change from 2000 to 2008 in Number of Physician Services Provided per 1,000 Medicare Beneficiaries Served in 

April, by State Urban and Rural Areas 

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

Urban areas within states

1.3 to 10.4 percentage change

10.5 to 12.8 percentage change

12.9 to 14.3 percentage change

14.4 to 23.7 percentage change

Notes: Beneficiaries and services were included in the count if the service was received in the first 28 

days of April and the claim was processed by the end of the third quarter of each calendar year. 

There were no rural areas in New Jersey, Rhode Island, and the District of Columbia. 

The average number of physician office visits—an indicator of beneficiary 

access to the typical entry point into the health care system and most 

basic level of physician services—rose for Medicare beneficiaries from 

April 2000 to April 2008. (See fig. 5.) The number of office visits increased 

during that period from about 29 to 31 (about 7 percent) per 1,000 

Page 18 GAO-09-559 Medicare Physician Services
 

Medicare beneficiaries for new patients and from about 442 to 504 (about 

14 percent) per 1,000 Medicare beneficiaries for established patients. 

Research indicates that an increased number of emergency room visits 

above the growth in physician services could signify problems accessing 

primary care because patients who have difficulties obtaining routine care 

may instead seek health care in emergency rooms.37 However, our analysis 

demonstrates similar increases in emergency room visits, total office 

visits, and overall physician services from 2000 to 2008. Specifically, 

emergency room visits rose from about 34 to 39 per 1,000 beneficiaries—

about 15 percent—which was approximately equal to the increase in total 

(new and established patient) office visits and the increase in the overall 

number of physician services per 1,000 beneficiaries treated. 

 

37Peter Cunningham and Jack Hadley, “Expanding Care Versus Expanding Coverage: How 

To Improve Access To Care,” Health Affairs, vol. 23, no. 4 (2004), and Medicare Payment 

Advisory Commission, Report to the Congress: Medicare Payment Policy, 93. 

Page 19 GAO-09-559 Medicare Physician Services
 

Figure 5: Numbers of Emergency Room Visits, Office Visits for New Patients, and Office Visits for Established Patients per 

1,000 FFS Medicare Beneficiaries in April, 2000-2008 

Visits per 1,000 beneficiaries

Emergency room visits

Office visits for new patients

Office visits for established patients

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

34 29

442

39 31

504

0

100

200

300

400

500

600

2000 2001 2002 2003 2004 2005 2006 2007 2008

Note: Beneficiaries and services were included in the count if the service was received in the first 28 

days of April and the claim was processed by the end of the third quarter of each calendar year. 

Indicators of Physician 

Willingness to Serve 

Medicare Beneficiaries 

Remain Favorable 

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 since 2000. (See fig. 6.) 

Specifically, the number of physicians billing Medicare increased from 

about 419,000 in April 2000 to about 474,000 in April 2007.38 The number of 

physicians continued to increase even as the number of beneficiaries in 

Medicare FFS declined over the last 2 years. The number of beneficiaries 

in traditional FFS Medicare decreased from about 33.4 million in 2005 to 

 

38These values are based on a count of unique physician identification numbers (UPIN) on 

Medicare Part B claims for physicians who performed services. As part of its transition to 

using the National Provider Identifier, in May 2007 CMS stopped issuing UPINs for 

physicians billing Medicare for the first time. Therefore, we were unable to obtain a 

comparable count of UPINs for 2008. 

Page 20 GAO-09-559 Medicare Physician Services
 

about 31.9 million in 2007, as more beneficiaries joined Medicare 

Advantage plans.39 Increases in the number of physicians billing Medicar

in spite of the decline in Medicare FFS beneficiaries, suggest that in the 

aggregate, ph

the number of physicians billing Medicare, 

ysicians continued to accept FFS Medicare patients during 

this period. 

edicare for Services Provided to Medicare Beneficiaries in April and Number of 

e, 

ysicians continued to accept FFS Medicare patients during 

this period. 

Figure 6: Number of Physicians Billing Medicare for Services Provided to Medicare Beneficiaries in April and Number of 

Medicare FFS Beneficiaries, 2000-2007 

380

390

400

410

420

430

440

450

460

470

480

2000 2001 2002 2003 2004 2005 2006 2007

Physicians (in thousands) FFS beneficiaries (in millions)

0

29

30

31

32

33

34

2000 2001 2002 2003 2004 2005 2006 2007

Total physicians Number of FFS beneficiaries

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

419

474

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

and their claim was processed by the end of the third quarter of each calendar year. We counted 

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

t 

t in 

 

e

From April 2000 to April 2008, the majority of Medicare physician services

were performed by physicians who accepted Medicare’s fees as paymen

in full. (See fig. 7.) In April 2000, about 98 percent of physician services 

were performed by physicians who accepted Medicare’s fee as paymen

39Medicare beneficiaries may choose how they receive services covered under Parts A and 

B. Most beneficiaries receive services through Medicare’s traditional FFS option and can 

obtain care from any licensed provider willing to accept Medicare patients. Beneficiaries 

can also enroll in the Medicare Advantage program, in which private health plans generally 

contract with providers to serve Medicare beneficiaries. 

Page 21 GAO-09-559 Medicare Physician Services
 

full (on assignment), and in April 2008, about 99 percent of physician 

services were paid on assignment. A smaller share of beneficiaries were 

likely subject to balance billing for physician services in April 2008 tha

April 2000, as the percentage of services for which physicians did not 

accept Medicare’s fee as payment in full decreased from about 1.8 percent 

to about 0.7 percent. The proportion of services provided by participating

physicians—that is, physicians who formally agreed to participate in the 

Medicare program and submit all claims 

about 95 percent in April 2

icipating

n in 

on assignment—increased from 

000 to about 

97 percent in April 2008.40

on assignment—increased from 

000 to about 

97 percent in April 2008.40

Figure 7: Proportion of Physician Services by Medicare Participation and Assignment Status 

Note: Services were counted if they were received in the first 28 days in April an

3.2%

Nonparticipating/

assigned

1.8%

Nonparticipating/

unassigned

95.0%

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

Participating/

assigned

2.1%

Nonparticipating/

assigned

0.7%

Nonparticipating/

unassigned

Participating/

assigned

97.2%

April 2000 April 2008

d claims for these 

rvices were processed by the end of the third quarter of each calendar year. 

 

se

40Physicians may decide on an annual basis whether they will be Medicare participating 

physicians. 

Page 22 GAO-09-559 Medicare Physician Services
 

Potentially overserved areas tend to be the more densely populated urban 

regions. Higher population density tended to increase an area’s likelihood 

of being potentially overserved. Nearly half of the 32 metropolitan 

divisions—the most densely populated group of areas—were potentially 

overserved. (See table 2.) Similarly, a little more than a quarter of large 

MSAs were potentially overserved while among small MSA areas and rural 

areas, barely 1 in 10 was potentially overserved.41

Table 2: Distribution of Utilization Status by Type of Geographic Area 

Percentage 

Type of geographic area Number of areas

Potentially 

overserved areas Other areas

Metropolitan divisions 32 47 53

Large MSAs 174 27 73

Small MSA areas 43 12 88

Rural areas 47 11 89

All areas 296 24 76

Potentially 

Overserved Areas 

Tend to Be in More 

Densely Populated 

Urban Regions and 

the Eastern Part of 

the Country 

Source: GAO analysis of data from the U.S. Census Bureau and Medicare Part B claims and enrollment data for April 2000 and April 

2008 from CMS. 

Notes: Connecticut, the District of Columbia, New Jersey and Rhode Island had no rural areas. 

Counties were mapped to metropolitan divisions based on U.S. Census Bureau designations. 

Nonrural counties outside of metropolitan divisions were mapped to MSAs based on U.S. Census 

Bureau and OMB designations. Small MSA areas are MSAs with fewer than 200,000 in population 

grouped together within each state. Rural areas include all rural counties within a state. 

Of the 296 geographic areas we examined, about one in four was 

potentially overserved—that is, they were in the top half of areas in both 

utilization of physician services in 2000 and growth in utilization of these 

services from 2000 to 2008. Areas that were in the top half in utilization in 

2000 were nearly as likely to be in the top half in growth from 2000 to 2008 

as areas that started in the bottom half in utilization. Specifically, of the 

148 areas that were in the top half in utilization in 2000, 72 were in the top 

half in growth from 2000 to 2008. (See table 10 in app. I.) Similarly, of the 

148 areas that were in the bottom half in utilization in 2000, 76 were in the 

top half in growth from 2000 to 2008. 

 

41In our analysis, we grouped small MSAs—that is, MSAs with fewer than 200,000 

residents—together within the same state. Counties outside of metropolitan divisions and 

MSAs were designated as rural areas and were similarly grouped together. 

Page 23 GAO-09-559 Medicare Physician Services
 

Potentially overserved areas and other areas experienced wide differences 

in utilization. These differences tended to be widest in the more densely 

populated regions. In 2000, the average number of services per beneficiary 

who received services was 3.58 in potentially overserved areas versus 3.24 

in other areas, or a difference of more than 10 percent. (See app. II for 

more information on utilization by type of geographic area.) Among areas 

with the largest populations—the metropolitan divisions and large MSAs—

average utilization in 2000 was 9 percent higher in potentially overserved 

areas, compared with a difference of about 5 percent among small MSA 

areas and 8 percent among rural areas. The growth in utilization from 2000 

to 2008 displayed a similar pattern. Overall, the average increase for 

potentially overserved areas was nearly 18 percent, while for other areas it 

was just over 12 percent. The average increase in utilization in potentially 

overserved metropolitan divisions was 21 percent, compared with 

12 percent in other metropolitan divisions. For the less densely populated 

areas, utilization also grew more rapidly in potentially overserved areas, 

although the gap in growth rates between potentially overserved and other 

areas tended to be smaller than it was for the metropolitan divisions. For 

example, the average increase in utilization was 17 percent in potentially 

overserved large MSAs, compared with 13 percent for other large MSAs. 

Our analysis found that areas in states east of the Mississippi River were 

much more likely to be potentially overserved. (See fig. 8.) Of the 174 

areas in states that are east of the Mississippi River, 60 were potentially 

overserved. For example, nearly the entire states of Alabama, Florida, and 

Illinois comprised potentially overserved areas. Of the 122 areas in states 

that are west of the Mississippi River, only 12 were potentially 

overserved.42

 

42We defined Arkansas, Iowa, Louisiana, Minnesota, Missouri, and all states to their west as 

“west of the Mississippi River.” 

Page 24 GAO-09-559 Medicare Physician Services
 

Figure 8: Geographic Areas by Type of Area and Utilization Status 

Source: GAO analysis of 2006 U.S. Census Bureau data and Medicare Part B claims data for April 2000 and April 2008.

Other areas

Potentially overserved rural areas

Potentially overserved small MSA areas

Potentially overserved large MSAs

Potentially overserved metropolitan divisions

Notes: We classified U.S. counties into one of four types of geographic areas: metropolitan divisions, 

large MSAs, small MSA areas, and rural areas. Potentially overserved areas are areas that were in 

the top half of areas in both utilization of physician services in 2000 and growth in utilization of 

physician services from 2000 to 2008. The rest of the areas were designated as other areas. 

Beneficiaries residing east of the Mississippi River are much more likely 

to reside in a potentially overserved area, because the most densely 

populated areas in the east are more likely to be potentially overserved 

than are those in the west. In 2008 nearly half the beneficiaries who 

resided in a state east of the Mississippi River were in a potentially 

Page 25 GAO-09-559 Medicare Physician Services
 

overserved area, while in the western part of the country only 

1 beneficiary in 10 resided in a potentially overserved area. In terms of 

population, the largest of the major metropolitan divisions east of the 

Mississippi River, including New York-White Plains, Chicago-NapervilleJoliet, and Philadelphia, were potentially overserved areas.43 In contrast, 

the largest western metropolitan divisions of Los Angeles-Long BeachGlendale, Dallas-Plano-Irving, and Santa Ana-Anaheim-Irvine were not 

potentially overserved areas by our measure.44 Similarly, beneficiaries in 

five of the six most populous large MSAs in the east were in potentially 

overserved areas, while beneficiaries in five of the six most populous large 

MSAs in the west were not. Only a minority of small MSA areas and rural 

areas in the east were potentially overserved and none of either of these 

two area types were potentially overserved in the west. (See app. III for a 

list of all areas.)45

Potentially overserved areas and other areas are largely similar in 

characteristics that could drive the use of physician services, including 

demographic characteristics and the capacity to provide health care 

services. In contrast, certain types of physician services are performed 

more frequently in potentially overserved areas than in other areas, 

suggesting differences in physician practice patterns. 

Potentially 

Overserved Areas Are 

Largely Similar to 

Other Areas, with the 

Exception of 

Physician Practice 

Patterns 

 

43Certain U.S. Census Bureau metropolitan divisions crossed state lines. In our analysis, we 

subdivided these entities into areas within states. 

44By labeling areas as “potentially overserved” and “other,” we do not suggest that the level 

of care in the other areas is uniformly appropriate. For example, the level of services 

provided in the Los Angeles-Long Beach-Glendale metropolitan division (see table 12 in 

app. III) was among the highest in the nation in both 2000 and 2008. However, because the 

growth rate was below the national median in this area, it did not meet our criteria for 

being placed in the potentially overserved category. 

45See app. V for more information on potentially overserved and other Medicare physician 

payment localities and app. VII for more information on potentially overserved and other 

hospital referral regions. 

Page 26 GAO-09-559 Medicare Physician Services
 

Potentially overserved and other areas appear similar in demographic 

characteristics that could be expected to affect the use of physician 

services. (See table 3.) For example, in 2006 Medicare beneficiaries in both 

groups of areas had similar risk scores, meaning they are expected to 

require similar amounts of Medicare resources because of their health 

status.46 Potentially overserved areas and other areas also had a similar 

racial composition and average income levels, although they differed 

somewhat in educational attainment.47 While these local factors are not 

under the control of the health care delivery system, they could be 

expected to influence the utilization of health care services. For example, 

income levels and insurance coverage have been shown to be related to 

patient preferences and demand for health care.48

Demographic 

Characteristics and 

Capacity to Provide Health 

Care Are Similar among 

Potentially Overserved and 

Other Areas 

 

46The risk scores are based on the demographics and diagnoses of the entire FFS 

population in a county and reflect the likelihood of needing more expensive care for 

Medicare Parts A and B combined. The population we used to determine whether an area is 

potentially overserved consists of beneficiaries who received Part B physician services in 

April 2000 or April 2008. 

47In the potentially overserved areas, 22.9 percent of the 2006 population attained at least 

4 years of college education, compared to 25.5 percent in other areas. 

48Newhouse et al., Free for All? Lessons from the RAND Health Insurance Experiment. 

Page 27 GAO-09-559 Medicare Physician Services
 

Table 3: Selected Demographic Characteristics in Potentially Overserved and Other 

Areas 

Potentially 

overserved areas Other areas

Deaths per 1,000 people, 2006 8.8 8.1

Average risk score, 2006a1.03 0.98

Average Medicare beneficiary age, 2008 71.2 70.8

Income per capita, 1999 $21,315 $21,653

Percentage of population enrolled in Medicare, 2007 11.7 10.8

Percentage of Medicare beneficiaries reporting having 

insurance in addition to Medicare 75 77

Percentage of population nonwhite, 2006 19.0 18.6

Percentage of population with at least 4 years of 

college education, 2006 22.9 25.5

Source: GAO analysis of Medicare Part B claims data, enrollment data, CAHPS survey data, and Medicare Advantage rate calculation 

data from CMS; ARF data from HRSA; and data from the U.S. Census Bureau. 

Notes: Data were the most recent available at the time of our analysis. We classified U.S. counties 

into one of four types of geographic areas: metropolitan divisions, large MSAs, small MSA areas, and 

rural areas. Potentially overserved areas are areas that were in the top half of areas in both utilization 

of physician services in April 2000 and growth in utilization of physician services from April 2000 to 

April 2008. The rest of the areas were designated as other areas. 

a

The risk scores are based on the demographics and diagnoses of the entire FFS population in a 

county and reflect the likelihood of needing more expensive care for Medicare Parts A and B 

combined. The population we used to determine whether an area is potentially overserved consists of 

beneficiaries who received Part B physician services in April 2000 or April 2008. 

Potentially overserved areas and other areas are also similar in terms of 

their capacities to provide health care services, as measured by number of 

beds and physicians per 1,000 people. (See table 4.) Specifically, in 2005, 

potentially overserved and other areas had a similar number of hospital 

beds per 1,000 people. In 2004, potentially overserved areas and other 

areas also had a similar number of physicians per 1,000 people. Studies 

have demonstrated strong associations between the number of hospital 

Page 28 GAO-09-559 Medicare Physician Services
 

beds and hospital utilization and between physician supply and the rate of 

physician visits.49

Table 4: Selected Health Care Capacity Characteristics in Potentially Overserved 

and Other Areas 

Potentially 

overserved areas Other areas 

Hospital beds per 1,000 population, 2005 3.4 3.5

Short-term hospital inpatient days per 

Medicare beneficiary, 2005 2.3 2.0

Number of physicians per 1,000 people, 2004 2.8 2.8

Ratio of primary care physicians to specialists, 2004 0.5 0.5

Source: GAO analysis of ARF data from HRSA. 

Notes: Data were the most recent available at the time of our analysis. We classified U.S. counties 

into one of four types of geographic areas: metropolitan divisions, large MSAs, small MSA areas, and 

rural areas. Potentially overserved areas are areas that were in the top half of areas in both utilization 

of physician services in April 2000 and growth in utilization of physician services from April 2000 to 

April 2008. The rest of the areas were designated as other areas. 

As table 4 shows, in 2004, potentially overserved areas and other areas had 

similar numbers of primary care physicians compared to specialists—

about a one-to-two ratio. Studies have shown that areas with higher ratios 

of primary care physicians to specialists have better health outcomes and 

better meet quality measures, such as administering beta-blockers after a 

heart attack or performing regular eye exams on diabetic patients.50

Conversely, studies have demonstrated that areas with more specialty 

 

49The view that health care supply creates its own demand is sometimes referred to as 

Roemer’s Law. M.I. Roemer and M. Shain, Hospital Utilization Under Insurance, Hospital 

Monograph Series No. 6 (Chicago: American Hospital Association, 1959); Fisher et al., “The 

Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and 

Accessibility of Care,” 273-287; Fisher et al., “The Implications of Regional Variations in 

Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,” 288-298; and E.S. 

Fisher, J.E. Wennberg, T.A. Stukel, and S.M. Sharp, “Hospital Readmission Rates for 

Cohorts of Medicare Beneficiaries in Boston and New Haven,” New England Journal of 

Medicine, vol. 331, no.15 (1994): 989-995. 

50K. Baicker and A. Chandra, “Medicare Spending, the Physician Workforce, and 

Beneficiaries’ Quality of Care,” Health Affairs, Web exclusive (Apr. 7, 2004): 184-197, and 

B. Starfield, L. Shi, and J. Macinko, “Contribution of Primary Care to Health Systems and 

Health,” The Milbank Quarterly, vol. 83, no. 3 (2005): 457-502. 

Page 29 GAO-09-559 Medicare Physician Services
 

services are associated with higher spending but not better access or 

health outcomes.51

Beneficiary Satisfaction Is 

Similar in Potentially 

Overserved and Other 

Areas 

Potentially overserved areas and other areas have similar Medicare 

beneficiary satisfaction, as measured by beneficiary perceptions of health 

care and health status. (See table 5.) For example, 94 percent of 

beneficiaries in potentially overserved areas reported having a personal 

doctor, compared to 93 percent of beneficiaries in other areas. 

Beneficiaries in both groups of areas also reported similar average health 

status, and similarly rated their health care and personal doctors highly. 

This finding is consistent with studies showing that geographic areas with 

high Medicare spending do not have better outcomes or perceptions of 

quality of medical care.52

 

51John E. Wennberg et al., Tracking the Care of Patients with Severe Chronic Illness: 

Dartmouth Atlas of Health Care 2008 (Lebanon, N.H.: 2008); Fisher et al., “The 

Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and 

Accessibility of Care,” 273-287; and Fisher et al., “The Implications of Regional Variations in 

Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,” 288-298. 

52Floyd J. Fowler, Jr., et al., “Relationship Between Regional Per Capita Medicare 

Expenditures and Patient Perceptions of Quality of Care,” Journal of the American 

Medical Association, vol. 299, no. 20 (2008): 2406-2412; Fisher et al., “The Implications of 

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

Care,” 273-287; and Fisher et al., “The Implications of Regional Variations in Medicare 

Spending. Part 2: Health Outcomes and Satisfaction with Care,” 288-298. 

Page 30 GAO-09-559 Medicare Physician Services
 

Table 5: Selected Medicare Beneficiary Satisfaction Indicators in Potentially 

Overserved and Other Areas, 2008 

Potentially 

overserved areas Other areas 

Percentage reporting having a personal doctor 94 93

Percentage reporting that it was never easy to 

schedule an appointment with a specialist 2 2

Percentage reporting never being able to promptly 

schedule an appointment for routine care 2 2

Self-reported health status 

(1=Excellent, 3=Good, 5=Poor) 3.1 3.1

Average rating of personal doctor 

(0=worst, 10=best) 8.9 8.9

Average rating of overall health care 

(0=worst, 10=best) 8.3 8.4

Source: GAO analysis of the Medicare CAHPS survey from CMS. 

Notes: The total number of individuals responding to each question varied. We report proportions of 

beneficiaries who were never able to easily schedule an appointment for routine care with a doctor or 

a specialist in the past 6 months only for those beneficiaries who needed routine care or a specialist. 

Similarly, we report beneficiary ratings of their personal doctor and overall health care only for those 

beneficiaries who visited a personal doctor or received health care services in the past 6 months. We 

classified U.S. counties into one of four types of geographic areas: metropolitan divisions, large 

MSAs, small MSA areas, and rural areas. Potentially overserved areas are areas that were in the top 

half of areas in both utilization of physician services in April 2000 and growth in utilization of physician 

services from April 2000 to April 2008. The rest of the areas were designated as other areas. 

Potentially Overserved and 

Other Areas Have 

Substantial Differences in 

Use of Certain Types of 

Physician Services 

When we compared types of physician services provided to Medicare 

beneficiaries, we found that potentially overserved areas and other areas 

differed in the frequency with which certain categories of physician 

services are used. (See table 6.) Specifically, we found that in April 2008, 

potentially overserved areas used substantially more evaluation and 

management services, minor procedures, and imaging services per 1,000 

beneficiaries than other areas. For example, potentially overserved areas 

had 44 percent more minor procedures—which include services such as 

ambulatory procedures, eye procedure treatments, and colonoscopies—

per 1,000 beneficiaries than other areas. Potentially overserved areas also 

had 29 percent more laboratory tests and 19 percent more imaging 

services per 1,000 beneficiaries than other areas. The two groups of areas, 

however, had similar rates of major procedures. (See app. IV for additional 

Page 31 GAO-09-559 Medicare Physician Services
 

trends in selected physician services in potentially overserved and other 

areas.)53

Table 6: Selected Physician Service Categories per 1,000 Medicare FFS 

Beneficiaries in Potentially Overserved and Other Areas, 2008 

Potentially 

overserved areas Other areas 

All services 2,247 1,812

Evaluation and management services 1,188 969

Procedures 

Majora 25 22

Minorb191 133

Imaging services 457 385

Laboratory tests 44 34

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

Notes: Beneficiaries and services were included in the count if the service was received in the first 28 

days of April and the claim was processed by the end of the third quarter of each calendar year. We 

classified U.S. counties into one of four types of geographic areas: metropolitan divisions, large 

MSAs, small MSA areas, and rural areas. Potentially overserved areas are areas that were in the top 

half of areas in both utilization of physician services in 2000 and growth in utilization of physician 

services from 2000 to 2008. The rest of the areas were designated as other areas. 

a

Major procedures is a clinical category defined by CMS, and includes physician services such as 

coronary artery bypass grafts, hip fracture repairs, and knee replacements. 

b

Minor procedures is a clinical category defined by CMS, and includes physician services such as 

ambulatory procedures, eye procedure treatments, and colonoscopies. 

We also found that specific services associated with the exercise of 

physician discretion are performed more frequently in potentially 

overserved areas, indicating differences in physician practice patterns. 

(See table 7.) When there is not a universally accepted treatment 

approach, the choice of services is subject to physician discretion. Several 

studies have identified certain services as prone to overuse or misuse for 

 

53See app. VI for trends in selected physician services in potentially overserved and other 

Medicare physician payment localities and app. VIII for trends in selected physician 

services in potentially overserved and other hospital referral regions. 

Page 32 GAO-09-559 Medicare Physician Services
 

various reasons, including physician discretion.54 Two of the three 

physician services identified in the literature as being related to physician 

discretion were performed substantially more frequently in potentially 

overserved areas than in other areas in April 2008. Advanced imaging 

services, which includes computed tomography (CT) and magnetic 

resonance imaging (MRI), were 16.1 percent more prevalent per 1,000 

beneficiaries in potentially overserved areas than in other areas in April 

2008.55 Electrocardiograms (EKG) were performed 30.1 percent more 

frequently per 1,000 beneficiaries in potentially overserved areas than in 

other areas. However, the frequency of knee replacements was similar in 

potentially overserved and other areas.56

 

54Wennberg et al., Tracking the Care of Patients with Severe Chronic Illness: Dartmouth 

Atlas of Health Care 2008; E.S. Fisher and J.E. Wennberg, “Health Care Quality, 

Geographic Variations, and the Challenge of Supply-Sensitive Care,” Perspectives in 

Biology and Medicine, vol. 46, no. 1, (Winter 2003): 69-79; Center for the Evaluative 

Clinical Sciences, Dartmouth Atlas Project Topic Brief: Effective Care (Lebanon, N.H.: 

2007); Center for the Evaluative Clinical Sciences, Dartmouth Atlas Project Topic Brief: 

Preference-Sensitive Care (Lebanon, N.H.: 2007); Center for the Evaluative Clinical 

Sciences, Dartmouth Atlas Project Topic Brief: Supply-Sensitive Care (Lebanon, N.H.: 

2007); and RAND, Assessing the Appropriateness of Care: How Much Is Too Much? 

(1998). 

55Imaging and diagnostic tests are examples of supply-sensitive care, a term used by the 

Dartmouth Atlas of Health Care to mean care for which the supply of resources partially 

determines the frequency of use. 

56Dartmouth researchers have identified knee replacements as an example of preferencesensitive care, meaning interventions for which there is a choice between at least two 

treatments that have different risks and benefits. Treatment choices among preferencesensitive care depend on patient preference and, often, physician discretion. 

Page 33 GAO-09-559 Medicare Physician Services
 

Table 7: Selected Physician Services per 1,000 Medicare FFS Beneficiaries in 

Potentially Overserved and Other Areas, 2008 

Potentially 

overserved areas Other areas 

Services associated with physician discretion 

Knee replacementa0.8 0.8

Advanced imagingb74.8 64.4

EKGb 85.2 65.5

Services not associated with physician discretion 

Hip surgery for hip fracturec0.4 0.4

Colonoscopy for cancer screeningc8.2 7.4

Cataract removald5.0 5.1

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

Notes: Beneficiaries and services were included in the count if the service was received in the first 28 

days of April and the claim was processed by the end of the third quarter of each calendar year. We 

classified U.S. counties into one of four types of geographic areas: metropolitan divisions, large 

MSAs, small MSA areas, and rural areas. Potentially overserved areas are areas that were in the top 

half of areas in both utilization of physician services in 2000 and growth in utilization of physician 

services from 2000 to 2008. The rest of the areas were designated as other areas. Physician services 

associated with physician discretion are situations in which there is not a universally accepted 

approach to treating the diagnosis. 

a

Dartmouth researchers have identified knee replacement as an example of preference-sensitive 

care, meaning interventions for which there is a choice between at least two treatments that have 

different risks and benefits. Treatment choices among preference-sensitive care depend on patient 

preference and, often, physician discretion. 

b

Dartmouth researchers have identified imaging and diagnostic testing as examples of supplysensitive care, meaning care for which supply of resources governs the frequency of use. 

c

Dartmouth researchers have identified hip surgery for hip fracture and colonoscopy for cancer 

screening as examples of situations in which there is a universally accepted approach to treating the 

diagnosis. 

d

Researchers at RAND identified cataract removal as a service with low rates of inappropriate use. 

We also found that two of three services identified in the literature as 

being universally accepted approaches to diagnoses or having low rates of 

inappropriate use were performed at similar frequencies in the two groups 

of areas in April 2008. Specifically, hip surgery for hip fracture and 

cataract removal were performed at similar frequencies in the two groups 

of areas. However, colonoscopy for cancer screening—another procedure 

identified in the literature as effective and strongly supported by 

evidence—was performed 10.8 percent more often per 1,000 beneficiaries 

in potentially overserved areas than in other areas in the United States. 

Page 34 GAO-09-559 Medicare Physician Services
 

Concluding 

Observations 

Although concerns have been raised that Congress’s efforts to control 

spending on physician services could limit beneficiary access to those 

services, our analysis suggests that beneficiary access generally remained 

the same or increased from 2000 to 2008. These findings are consistent 

with our earlier work. However, we also found that some geographic areas 

of the country experienced much higher levels of utilization of physician 

services and much greater increases in utilization compared to the rest of 

the nation—which may indicate excessive care not driven by medical 

need. Our definition of areas that are potentially overserved was based on 

both levels of service and growth rates, while past research has generally 

concentrated on levels of service. Nevertheless, our findings are consistent 

with past research—they underscore the importance of geography in the 

utilization of physician services and can help inform ongoing discussions 

regarding Medicare physician payment reform. Medicare’s SGR, which is 

used to help control spending on physician services, does not account for 

geographic differences in utilization rates. As Congress considers options 

for revising the SGR and other payment reforms, the issue of geographic 

differences will likely continue to be part of this discussion. 

Agency and Industry 

Comments and Our 

Evaluation 

Agency Comments In written comments on a draft of this report, CMS noted the agency’s 

longstanding practice of monitoring the effect of policy changes on 

beneficiary access to Medicare services, and stated that this report would 

help in that effort. We have reprinted CMS’s letter in appendix IX. 

American Medical 

Association Comments 

We obtained oral comments on a draft of our report from an official 

representing the American Medical Association (AMA). The AMA official 

shared two overall observations. First, the AMA official said that the rate 

of growth in per beneficiary utilization of physician services had declined 

each year since 2004. While the growth rate has not been uniform, our 

report finds that an increasing number of services were provided to 

beneficiaries who were treated by a physician from April 2000 to April 

2008. Second, the AMA official said that beneficiaries could face access 

problems that would not appear in our analysis of survey and claims data. 

The AMA official explained, for example, that physicians could increase 

the number of claims they submit, while seeing fewer patients or could be 

Page 35 GAO-09-559 Medicare Physician Services
 

accepting fewer Medicare beneficiaries seeking new appointments. 

However, the three overall indicators we constructed to measure access 

trends—from both the beneficiary and physician perspective—

demonstrated sustained beneficiary access to services. As we reported in 

our draft, we found very few beneficiaries reporting major access 

difficulties in 2007 and 2008, the utilization of services increased 

nationwide from April 2000 to April 2008, and physician participation in 

Medicare also rose over this period. The AMA official also shared 

technical comments with us, which we incorporated into our report as 

appropriate. 

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At the time, we will send copies to the Acting Administrator of 

CMS and interested congressional committees. The report also will be 

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

If you or your staff have any questions, please contact me at (202) 512-7114 

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 major contributions to this report are listed in 

A. Bruce Stei

appendix X. 

nwald 

Director, Health Care 

Page 36 GAO-09-559 Medicare Physician Services
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

This appendix explains the scope and methodology that we used to 

address our reporting objectives. Specifically, we wanted to (1) determine 

how beneficiary access to physician services has changed from 2000 to 

2008; (2) identify areas of the country where Medicare beneficiaries are 

potentially overserved by physicians; and (3) describe characteristics that 

distinguish potentially overserved areas from other areas in the nation. 

To determine how beneficiary access to physician services changed from 

2000 to 2008, we constructed three types of indicators to measure 

beneficiary access to physician services: beneficiary perceptions about 

access, utilization of physician services, and indicators of physicians’ 

willingness to participate in Medicare and serve Medicare beneficiaries. To 

measure beneficiary perceptions of access, we analyzed 2007 and 2008 

responses to the Consumer Assessment of Healthcare Providers and 

Systems (CAHPS) survey conducted by the Centers for Medicare & 

Medicaid Services (CMS). We used CAHPS survey data that asked 

beneficiaries to describe their experiences with the Medicare fee-forservice (FFS) program.1

 These annual surveys are a nationally 

representative source of Medicare beneficiary perceptions of their access 

to health care that would enable comparisons over time among states and 

between urban and rural areas. Respondents were asked about their 

experiences in the 6 months before the survey.2

 CMS surveyed 

approximately 431,000 FFS beneficiaries in the spring of 2007 and 

approximately 306,000 in the spring of 2008. We excluded responses from 

beneficiaries residing outside the 50 states and the District of Columbia 

from our analysis. The number of FFS beneficiaries residing in the areas 

that were part of our analysis who completed the survey was 199,000 in 

2007 and 163,000 in 2008.3

 

1

Medicare is the federally financed health insurance program for persons aged 65 and over, 

certain individuals with disabilities, and individuals with end-stage renal disease. Eligible 

individuals are automatically covered by Medicare Part A, which covers hospital and other 

inpatient stays. Medicare Part B is optional insurance and covers hospital outpatient, 

physician, and other services. Medicare Parts A and B are known as traditional Medicare or 

Medicare FFS. 

2

We analyzed the CAHPS survey of FFS beneficiaries, including respondents with and 

without Part D coverage. 

3

According to CMS officials, fewer beneficiaries were surveyed in 2008 because of resource 

limitations. 

Page 37 GAO-09-559 Medicare Physician Services 
Appendix I: Scope and Methodology 

We focused on two CAHPS questions that were related to beneficiary 

access to physician services. The questions, reproduced in table 8, asked 

about the ease of scheduling prompt appointments for routine care and 

beneficiary ability to gain access to specialists. For each question, we 

included only the responses from those beneficiaries who could have 

encountered an access problem—that is, those who reported trying to 

schedule an appointment with any doctor and those who attempted to 

make an appointment to see a specialist. 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 

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

respondents who responded the most negatively—those who responded 

that they were “never” able to schedule an appointment as soon as they 

thought they needed it. 

Table 8: Selected CAHPS Survey Questions Related to Beneficiary Access to Physician Services, 2008 

Respondents 

included in analysis 

Percentage of 

all survey respondents Question 

Possible 

responses 

Beneficiaries who reported making 

an appointment at a doctor’s office 

and clinic with the exception of 

those who needed care right away. 

81 In the last 6 months, not counting the times you 

needed care right away, how often did you get 

an appointment for your health care at a doctor’s 

office or clinic as soon as you thought you 

needed? 

Never 

Sometimes 

Usually 

Always 

Beneficiaries who reported trying to 

make an appointment to see a 

specialist 

53 In the last 6 months, how often was it easy to get 

appointments with specialists? 

Never 

Sometimes 

Usually 

Always 

Source: GAO analysis of the 2008 Medicare CAHPS survey conducted by CMS. 

We also examined whether these responses varied by state or between 

urban and rural areas nationwide. 

To analyze Medicare beneficiary access to physician services based on 

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 2008, which yielded 

Page 38 GAO-09-559 Medicare Physician Services
Appendix I: Scope and Methodology 

more than 60 million claims per year.4 These claims represent an annual 

snapshot of beneficiary access to physician services for each of the 

9 years. We selected April to allow time for the annual fee updates to be 

implemented beginning January 1 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. 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 6 years in which fee 

increases were less than the growth in the estimated cost of providing 

services (2003 through 2008).5

 We established a consistent cutoff date (the 

last Friday in September of each year) for each year’s data file and only 

included those claims for April services that had been processed by that 

date.6

 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. To determine the number of FFS beneficiaries, we used the April 

enrollment data from the Denominator file—a database that contains 

enrollment data and entitlement status for all Medicare beneficiaries 

enrolled, entitled, or both in each month in a given year. 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 (OMB) 

classification of metropolitan statistical areas (MSA). We constructed 

multiple utilization measures to determine whether Medicare beneficiaries 

experienced changes in their access to physician services; these indicators 

included 

 

4

We excluded claims for services provided by nurse practitioners, physician assistants, and 

other nonphysician practitioners. We included services covered by the fee schedule—such 

as office visits, major and minor surgeries, and imaging services—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. 

5

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. 

6

We chose September so our data would include up to 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. 

Page 39 GAO-09-559 Medicare Physician Services
Appendix I: Scope and Methodology 

• the percentage of Medicare FFS beneficiaries obtaining services in April of 

each year and 

• the number of physician services per 1,000 beneficiaries 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 and emergency room visits. 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.7

To indicate physicians’ willingness to participate in Medicare, we 

determined the number of physicians billing Medicare from 2000 through 

2007,8

 whether services were performed by participating or 

nonparticipating physicians, and whether claims for physician services 

were paid on assignment or not on assignment.9

 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. 

To identify areas of the country where Medicare beneficiaries are 

potentially overserved by physicians, we identified areas of the country 

where utilization of physician services in Medicare is potentially excessive. 

Because policymakers have expressed concerns about both the level and 

growth of services in the Medicare program, we incorporated both factors 

in our measure of potential overservice. Specifically, we identified areas 

that were both relatively high in their level of utilization and relatively high 

in their growth in utilization. We analyzed one of our access indicators, 

services per beneficiary served, to measure potential overutilization. Using 

 

7

There are no rural counties in Rhode Island, New Jersey, and the District of Columbia. 

8

These values are based on a count of unique physician identification numbers (UPIN) on 

Medicare FFS claims for physicians who performed services. As part of its transition to 

using the National Provider Identifier, in May 2007 CMS stopped issuing UPINs for 

physicians billing Medicare for the first time. 

9

Physicians who “accept assignment” are those who agree to accept Medicare’s fee as 

payment in full. The fee includes the coinsurance amount (usually 20 percent) paid by the 

beneficiary. Participating physicians must accept assignment for all Medicare-covered 

services that they provide to beneficiaries. 

Page 40 GAO-09-559 Medicare Physician Services
Appendix I: Scope and Methodology 

the U.S. Census Bureau10 and OMB classifications, we divided states into 

urban and rural areas and made additional distinctions among urban areas, 

allowing us to classify counties into one of four types of areas, as shown in 

table 9.11

Table 9: Geographic Area Types for Utilization Analysis 

Geographic area Method of selection Number of areas

Percentage 

share of 

U.S. population

Metropolitan divisions Identified by the U.S. Census Bureau 32 26

Large MSAs MSAs with 200,000 or more in population 174 49

Small MSAs combined within states A combination of MSAs within the same state with 

fewer than 200,000 residents 43 6

Rural areas combined within states A combination of counties within the same state that 

were outside of metropolitan divisions and MSAs 47 19

Source: GAO analysis of U.S. Census Bureau data and Medicare Part B claims and enrollment data. 

Note: Area types are listed in descending order of population density. 

We did not allow areas to cross state lines, so a metropolitan division or 

MSA that crossed state lines was subdivided into separate areas for each 

state. We examined a total of 296 areas, ranking them by their level of 

utilization in 2000 and their change in utilization from 2000 to 2008. To 

determine an area’s utilization status, we designated areas in the top half 

of both measures as “potentially overserved” and the rest as “other” areas. 

(See table 10.) This method resulted in 72 of the 296 areas being 

designated as potentially overserved.12

 

10We referenced counties to MSAs and metropolitan divisions using U.S. Census Bureau 

data from the Missouri Census Data Center. 

11We excluded four counties with low populations because they lacked data on Medicare 

enrollment or utilization of physician services. 

12We also analyzed utilization of physician services in Medicare’s 87 physician payment 

localities and in the 306 hospital referral regions (HRR) as defined by the Dartmouth Atlas 

Project. We combined certain Medicare physician payment localities in California, Kansas, 

and Missouri. We ranked both the Medicare physician payment localities and the HRRs by 

their level of utilization in 2000 and their change in utilization from 2000 to 2008. To 

determine the utilization status of either a Medicare physician payment locality or an HRR, 

we designated areas in the top half of both measures as “potentially overserved” and the 

rest as “other” areas. 

Page 41 GAO-09-559 Medicare Physician Services
Appendix I: Scope and Methodology 

Table 10: Distribution of Geographic Areas by Ranking 

Ranking by change in the number of 

services per beneficiary served, 

2000 to 2008 

Ranking by number of services 

per beneficiary served, 2000 Top half Bottom half Total

Top half 72 76 148

Bottom half 76 72 148

Total 148 148 296

Source: GAO analysis of U.S. Census Bureau data and Medicare Part B claims data for April 2000 and April 2008. 

To describe characteristics that distinguish potentially overserved areas 

from other areas in the nation, we reviewed literature to identify 

characteristics that could drive the use of physician services.13 Using the 

most recently available data sources, we constructed several area-level 

characteristics and compared them between potentially overserved areas 

and all other areas. Specifically we compared various demographic 

characteristics and compared the capacity to provide health care 

services—both of which are factors that could drive the use of physician 

services. We also compared beneficiary satisfaction with their health care 

and the types of physician services provided in the two types of areas. We 

examined the provision of physician services broadly. However, our 

review of clinical and economic studies in the literature suggested that 

certain services might be or might not be prone to overuse and thus we 

also compared the utilization of these services for both potentially 

overserved and other areas. We obtained demographic data on mortality, 

race, and education as well as data on health services capacity from the 

Area Resource File (ARF), a national county-level health resource 

information database produced by the Health Resources and Services 

Administration of the Department of Health and Human Services; 

population and income data from the U.S. Census Bureau; beneficiary age 

and enrollment data from the Denominator file; and risk score data from 

the CMS Medicare Advantage rate calculation data for 2009.14 We obtained 

 

13We were not able to obtain data to account for all the factors that might explain 

differences in utilization. For example, we were unable to find sufficient data to measure 

the level of coordinated care across all areas. 

14Risk scores are based on the demographics and diagnoses of the entire FFS population in 

a county and reflect the likelihood of greater combined Medicare Part A and Part B 

expenditures. Geographic area risk scores are the population-weighted average of risk 

scores for the counties within an area. 

Page 42 GAO-09-559 Medicare Physician Services
Appendix I: Scope and Methodology 

data on beneficiary perceptions and satisfaction with care from the 2008 

CAHPS survey. We used Medicare Part B claims to obtain physician 

services utilization data. 

As part of our analysis we found that potentially overserved areas were 

more likely to be urban—that is, have greater population density—than 

other areas. Therefore, when comparing various characteristics of 

potentially overserved areas and other areas, we accounted for this 

difference in population density by weighting the data from other areas to 

reflect the same proportion of urbanization found in potentially 

overserved areas. 

We also analyzed the utilization of specific types of physician services in 

potentially overserved and other areas. This analysis was based on the 

Berenson-Eggers Type of Service (BETOS) code assigned to each 

physician service in the Part B claims data. According to 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. We compared the number of services per 1,000 Medicare 

FFS beneficiaries in potentially overserved and other areas for selected 

service categories.15 We collapsed data on other services and procedures 

into summary categories. 

Data Reliability and 

Limitations 

We took several steps to ensure that the CAHPS, Medicare claims and 

enrollment, U.S. Census Bureau, and ARF data were sufficiently reliable 

for our analysis. For the CAHPS survey data, we examined the accuracy 

and completeness of the data by testing for implausible values and internal 

consistency and reviewed relevant documentation.16 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. Our analysis of the 

proportion of beneficiaries reporting major difficulties accessing physician 

 

15Using the BETOS codes, we also compared the utilization of specific types of physician 

services in potentially overserved and other Medicare physician payment localities and in 

potentially overserved and other HRRs. 

16In order to ensure the consistency of individuals’ responses to both the question on the 

need for care and the related access question, we used recoded survey responses. For 

example, if an individual answered in a prior question that he or she did not need a 

specialist, the recoded response on the access question related to specialists was “not 

applicable.” 

Page 43 GAO-09-559 Medicare Physician Services
Appendix I: Scope and Methodology 

services was limited to beneficiaries who needed an appointment for 

either routine or specialist care; it does not refer to the entire population 

of Medicare beneficiaries. 

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 existing information about the data, including the 

data dictionary and file layouts. We also interviewed knowledgeable CMS 

officials about the data. 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 assessed the reliability of the U.S. Census 

Bureau and ARF data by reviewing relevant documentation and examining 

the data for obvious errors. 

We conducted this performance audit from May 2008 through August 2009 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives. 

Page 44 GAO-09-559 Medicare Physician Services
Appendix II: Average Utilization Values by Appendix II: Average Utilization Values by Geographic Area Type 

Geographic Area Type 

We classified geographic areas of the country by type of area and 

utilization status. Our measure of utilization—services per beneficiary 

served—is based on Medicare claims data for services performed in the 

first 28 days of April 2000 and April 2008. An area was designated as 

potentially overserved if it was in both the top half of all areas in number 

of services per beneficiary served in 2000 and in the top half of the growth 

rate in services per beneficiary served from 2000 to 2008. Table 11 

presents information, by geographic area type and utilization status, on the 

average number of services per beneficiary in 2000 and 2008, and the 

average change in the number of services per beneficiary from 2000 to 

2008. 

Table 11: Average Utilization by Geographic Area Type 

Utilization status 

Average number 

services per 

beneficiary served, 

2000 

Average number of 

services per 

beneficiary served, 

2008 

Average percentage 

change in services per 

beneficiary served, 

2000 to 2008b

Geographic 

area typea

Potentially 

overserved 

areas 

Other 

areas 

Potentially 

overserved 

areas

Other 

areas

Potentially 

overserved 

areas

Other 

areas 

Potentially 

overserved 

areas

Other 

areas

Metropolitan 

divisions 15 17 3.84 3.52 4.65 3.93 21.02 12.03

Large MSAs 47 127 3.54 3.25 4.15 3.66 17.16 13.07

Small MSA areas 5 38 3.42 3.25 3.97 3.61 16.15 11.19

Rural areas 5 42 3.36 3.12 3.86 3.46 14.69 11.12

All areas 72 224 3.58 3.24 4.22 3.64 17.72 12.31

Source: GAO analysis of U.S. Census Bureau data and Medicare Part B claims and enrollment data for 2000 and 2008 from CMS. 

a

Counties were mapped to metropolitan divisions based on U.S. Census Bureau designations. 

Nonrural counties outside of metropolitan divisions were mapped to MSAs based on U.S. Census 

Bureau and OMB designations. Small MSA areas are MSAs with fewer than 200,000 in population 

grouped together within each state. Rural areas include all rural counties within a state. 

b

The percentages presented in this table represent the average percentages of individual areas within 

each geographic area type. 

Page 45 GAO-09-559 Medicare Physician Services 
Appendix III: Utilization Status of Geographic 

Areas 

Page 46 GAO-09-559 

Appendix III: Utilization Status of Geographic 

Areas 

We identified potentially overserved areas of the country by classifying 

U.S. counties into one of four types of geographic areas: metropolitan 

divisions, large MSAs, small MSA areas, and rural areas. This classification 

process yielded 296 areas across the United States. We measured 

utilization in each of these areas by examining the number of services per 

beneficiary who received services in April 2000 and April 2008, and ranked 

them by their level of utilization in 2000 and changes in utilization from 

2000 to 2008. To determine an area’s utilization status, we designated areas 

in the top half of both measures as potentially overserved areas and 

designated the rest as other areas. Across all areas, the median number of 

services per beneficiary served was 3.28 in 2000 and 3.71 in 2008. The 

median percentage change in services per beneficiary served from 2000 to 

2008 was 13.7. (See table 12.) 

Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

Table 12: Utilization Status of Geographic Areas 

State Area name Statusa

Type of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Alabama Birmingham Potentially 

overserved area 

Large MSA 975,560 3.38 3.91 15.8

Alabama Huntsville Other area Large MSA 386,632 3.27 3.82 17.0

Alabama Mobile Other area Large MSA 576,175 3.59 4.06 13.2

Alabama Montgomery Potentially 

overserved area 

Large MSA 353,276 3.30 3.76 14.2

Alabama Small 

metropolitan areas 

Other area Small MSA 

areas 

1,012,674 3.40 3.82 12.5

Alabama Rural counties Potentially 

overserved area 

Rural areas 1,323,534 3.30 3.78 14.4

Alaska Anchorage Other area Large MSA 279,671 3.30 3.49 5.6

Alaska Rural counties Other area Rural areas 403,807 3.29 3.39 2.8

Arizona Phoenix-Mesa Potentially 

overserved area 

Large MSA 4,179,427 3.60 4.21 16.9

Arizona Tucson Potentially 

overserved area 

Large MSA 967,089 3.29 3.89 18.3

Arizona Small 

metropolitan areas 

Other area Small MSA 

areas 

512,951 3.51 3.94 12.3

Arizona Rural counties Other area Rural areas 679,288 3.18 3.66 14.8

Arkansas FayettevilleSpringdale-Rogers Other area Large MSA 397,399 3.15 3.52 11.7

Arkansas Little RockNorth Little Rock Other area Large MSA 638,550 3.63 3.96 9.3

Arkansas Small 

metropolitan areas 

Other area Small MSA 

areas 

446,100 3.33 3.69 10.8

Arkansas Rural counties Other area Rural areas 1,352,748 3.32 3.69 11.1

California Los AngelesLong BeachGlendale Other area Metropolitan 

division 

9,878,554 4.48 4.63 3.4

California Oakland-FremontHayward Other area Metropolitan 

division 

2,483,842 3.23 3.76 16.5

California San FranciscoSan MateoRedwood City Other area Metropolitan 

division 

1,720,056 3.17 3.60 13.8

California Santa AnaAnaheim-Irvine Other area Metropolitan 

division 

2,997,033 3.98 4.37 9.6

Page 47 GAO-09-559 Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

State Area name Statusa Type of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

California Bakersfield Potentially 

overserved area 

Large MSA 790,710 3.67 4.24 15.4

California Chico-Paradise Other area Large MSA 218,779 3.06 3.47 13.6

California Fresno Other area Large MSA 1,045,861 3.12 3.66 17.3

California Merced Other area Large MSA 245,514 3.33 3.67 10.2

California Modesto Other area Large MSA 511,263 3.10 3.61 16.2

California Riverside CountycOther area Large MSA 4,879,735 3.75 4.07 8.5

California Sacramento-Yolo Other area Large MSA 2,091,120 3.18 3.46 8.7

California Salinas Other area Large MSA 407,637 3.29 3.55 7.9

California San Diego Other area Large MSA 2,974,859 3.56 3.98 12.0

California San Luis ObispoAtascaderoPaso Robles Other area Large MSA 262,436 3.09 3.49 12.7

California Santa BarbaraSanta MariaLompoc Other area Large MSA 404,197 3.43 3.64 6.2

California Santa Clara 

Countyc

Other area Large MSA 3,006,322 3.07 3.58 16.7

California Stockton-Lodi Other area Large MSA 670,990 3.16 3.51 10.9

California Small 

metropolitan areas 

Other area Small MSA 

areas 

343,565 3.39 3.68 8.6

California Rural counties Other area Rural areas 1,199,189 3.16 3.39 7.3

Colorado Colorado Springs Other area Large MSA 587,272 3.17 3.68 16.1

Colorado DenverBoulder-Greeley Potentially 

overserved area 

Large MSA 2,945,107 3.29 3.77 14.6

Colorado Fort CollinsLoveland Other area Large MSA 287,574 3.02 3.52 16.3

Colorado Small 

metropolitan areas 

Other area Small MSA 

areas 

293,620 2.92 3.28 12.3

Colorado Rural counties Other area Rural areas 747,942 2.92 3.28 12.4

Connecticut Fairfield CountycOther area Large MSA 1,928,782 3.28 3.95 20.6

Connecticut Hartford Other area Large MSA 1,306,151 3.00 3.61 20.3

Connecticut New LondonNorwich Other area Large MSA 267,376 3.09 3.83 23.9

Delaware Wilmington Other area Metropolitan 

division 

528,218 3.27 3.97 21.5

Delaware Small 

metropolitan areas 

Potentially 

overserved area 

Small MSA 

areas 

152,255 3.32 3.90 17.5

Page 48 GAO-09-559 Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

State Area name Statusa Type of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Delaware Rural counties Other area Rural areas 184,291 3.34 3.72 11.6

District of 

Columbia 

Washingtonc Other area Metropolitan 

division 

588,292 3.86 4.22 9.2

Florida Fort LauderdalePompano BeachDeerfield Beach Potentially 

overserved area 

Metropolitan 

division 

1,759,591 4.24 5.13 21.1

Florida Miami-Miami 

Beach-Kendall 

Potentially 

overserved area 

Metropolitan 

division 

2,387,170 4.53 5.15 13.7

Florida West Palm BeachBoca RatonBoynton Beach Potentially 

overserved area 

Metropolitan 

division 

1,266,451 4.25 5.15 21.4

Florida Daytona Beach Other area Large MSA 588,810 3.27 4.08 24.8

Florida Fort MyersCape Coral Potentially 

overserved area 

Large MSA 590,564 3.55 4.48 26.1

Florida Fort PiercePort St. Lucie Potentially 

overserved area 

Large MSA 400,121 3.81 4.56 19.4

Florida Gainesville Potentially 

overserved area 

Large MSA 240,082 3.35 3.92 17.1

Florida Jacksonville Potentially 

overserved area 

Large MSA 1,275,078 3.83 4.59 20.0

Florida LakelandWinter Haven Potentially 

overserved area 

Large MSA 574,746 3.47 4.14 19.3

Florida MelbourneTitusvillePalm Bay Potentially 

overserved area 

Large MSA 536,161 3.66 4.43 21.1

Florida Naples Potentially 

overserved area 

Large MSA 315,839 3.88 4.63 19.4

Florida Ocala Potentially 

overserved area 

Large MSA 324,857 3.45 4.02 16.7

Florida Orlando Potentially 

overserved area 

Large MSA 2,032,496 3.65 4.32 18.3

Florida Pensacola Potentially 

overserved area 

Large MSA 453,451 3.32 3.81 14.9

Florida SarasotaBradenton Potentially 

overserved area 

Large MSA 687,181 3.61 4.33 20.2

Florida Tallahassee Other area Large MSA 308,142 3.08 3.62 17.6

Florida TampaSt. PetersburgClearwater Potentially 

overserved area 

Large MSA 2,723,949 3.75 4.47 19.2

Page 49 GAO-09-559 Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

State Area name Statusa Type of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Florida Small 

metropolitan areas 

Potentially 

overserved area 

Small MSA 

areas 

498,297 3.69 4.34 17.9

Florida Rural counties Potentially 

overserved area 

Rural areas 1,288,257 3.60 4.18 16.1

Georgia Atlanta Potentially 

overserved area 

Large MSA 5,122,983 3.31 3.88 17.4

Georgia AugustacOther area Large MSA 328,023 3.26 3.44 5.6

Georgia Columbus Other area Large MSA 225,549 3.10 3.55 14.5

Georgia Macon Other area Large MSA 348,906 3.24 4.00 23.5

Georgia Savannah Other area Large MSA 329,329 3.52 3.92 11.6

Georgia Small 

metropolitan areas 

Other area Small MSA 

areas 

445,078 3.33 3.60 8.1

Georgia Rural counties Other area Rural areas 2,744,882 3.19 3.59 12.7

Hawaii Honolulu Other area Large MSA 905,601 3.04 3.29 8.5

Hawaii Rural counties Other area Rural areas 377,668 2.93 3.12 6.6

Idaho Boise City Other area Large MSA 552,787 2.90 3.23 11.6

Idaho Small 

metropolitan areas 

Other area Small MSA 

areas 

79,925 2.72 2.99 9.6

Idaho Rural counties Other area Rural areas 866,690 2.91 3.14 7.7

Illinois ChicagoNaperville-Joliet Potentially 

overserved area 

Metropolitan 

division 

7,952,540 3.71 4.48 20.7

Illinois Lake CountycPotentially 

overserved area 

Metropolitan 

division 

710,241 3.41 4.28 25.6

Illinois Madison Countyc Potentially 

overserved area 

Large MSA 619,940 3.35 3.82 13.9

Illinois Peoria-Pekin Other area Large MSA 352,164 3.15 3.63 15.2

Illinois Rockford Other area Large MSA 407,301 3.12 3.81 22.2

Illinois Springfield Potentially 

overserved area 

Large MSA 206,588 3.35 4.01 19.7

Illinois Small 

metropolitan areas 

Potentially 

overserved area 

Small MSA 

areas 

770,889 3.29 3.83 16.2

Illinois Rural counties Potentially 

overserved 

Rural areas 1,832,885 3.30 3.76 13.9

Indiana Gary Potentially 

overserved area 

Metropolitan 

division 

652,682 3.56 4.45 24.7

Indiana Clark CountycPotentially 

overserved area 

Large MSA 238,588 3.43 4.01 16.9

Indiana EvansvillecOther area Large MSA 257,777 3.05 3.70 21.3

Page 50 GAO-09-559 Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

State Area name Statusa Type of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Indiana Fort Wayne Other area Large MSA 523,253 2.99 3.56 19.2

Indiana Indianapolis Other area Large MSA 1,774,665 3.19 3.64 14.4

Indiana South Bend Other area Large MSA 266,088 2.98 3.64 21.9

Indiana Small 

metropolitan areas 

Other area Small MSA 

areas 

942,519 3.14 3.66 16.8

Indiana Rural counties Other area Rural areas 1,689,717 3.05 3.49 14.7

Iowa Cedar Rapids Other area Large MSA 205,836 3.09 3.40 10.1

Iowa Des Moines Other area Large MSA 520,130 3.43 3.67 6.9

Iowa Small 

metropolitan areas 

Other area Small MSA 

areas 

699,880 3.25 3.59 10.4

Iowa Rural counties Other area Rural areas 1,562,200 3.06 3.35 9.6

Kansas Johnson CountycOther area Large MSA 784,956 3.60 3.90 8.5

Kansas Wichita Other area Large MSA 572,564 3.26 3.66 12.4

Kansas Small 

metropolitan areas 

Other area Small MSA 

areas 

286,964 3.03 3.45 14.0

Kansas Rural counties Other area Rural areas 1,131,513 3.15 3.51 11.4

Kentucky Kenton CountycOther area Large MSA 404,246 3.25 4.13 27.0

Kentucky Lexington Other area Large MSA 528,276 3.10 3.67 18.5

Kentucky LouisvillecPotentially 

overserved area 

Large MSA 839,130 3.65 4.20 15.1

Kentucky Small 

metropolitan areas 

Other area Small MSA 

areas 

333,095 3.52 3.90 10.8

Kentucky Rural counties Other area Rural areas 2,136,727 3.26 3.71 13.8

Louisiana Baton Rouge Other area Large MSA 668,578 3.76 3.97 5.7

Louisiana Houma Potentially 

overserved area 

Large MSA 201,137 3.40 3.90 14.7

Louisiana Lafayette Other area Large MSA 407,814 3.46 3.89 12.5

Louisiana New Orleans Other area Large MSA 1,051,941 3.75 4.20 12.1

Louisiana ShreveportBossier City Other area Large MSA 402,238 3.58 3.98 11.3

Louisiana Small 

metropolitan areas 

Other area Small MSA 

areas 

464,093 3.65 3.90 6.7

Louisiana Rural counties Other area Rural areas 1,097,403 3.54 4.01 13.1

Maine Portland Other area Large MSA 275,374 3.16 3.34 5.8

Maine York CountycOther area Large MSA 201,341 3.07 3.42 11.3

Page 51 GAO-09-559 Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

State Area name Statusa Type of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Maine Small 

metropolitan areas 

Other area Small MSA 

areas 

330,497 3.13 3.25 3.8

Maine Rural counties Other area Rural areas 509,995 2.97 3.18 7.0

Maryland BethesdaFrederickGaithersburg Other area Metropolitan 

division 

1,155,518 3.59 4.06 13.3

Maryland Prince George’s 

Countyc

Other area Metropolitan 

division 

1,057,437 3.80 4.08 7.5

Maryland Baltimorec Other area Large MSA 2,813,169 3.47 3.88 11.8

Maryland Small 

metropolitan areas 

Other area Small MSA 

areas 

172,289 3.48 3.84 10.4

Maryland Rural counties Potentially 

overserved area 

Rural areas 419,931 3.33 3.82 14.5

Massachusetts Boston-Quincy Other area Metropolitan 

division 

1,858,216 3.49 3.83 9.8

Massachusetts Essex Other area Metropolitan 

division 

733,101 3.37 3.80 12.8

Massachusetts NewtonFraminghamc

Other area Metropolitan 

division 

1,473,416 3.43 3.78 10.2

Massachusetts BarnstableYarmouth Other area Large MSA 222,175 3.21 3.64 13.6

Massachusetts Springfield Other area Large MSA 682,657 3.12 3.50 12.3

Massachusetts Worcester CountycOther area Large MSA 1,324,376 3.31 3.70 11.7

Massachusetts Small 

metropolitan areas 

Other area Small MSA 

areas 

129,798 3.13 3.71 18.4

Massachusetts Rural counties Other area Rural areas 26,016 3.07 3.43 11.6

Michigan Detroit-LivoniaDearborn Potentially 

overserved area 

Metropolitan 

division 

1,985,101 3.87 4.76 23.1

Michigan Warren-TroyFarmington Hills Potentially 

overserved area 

Metropolitan 

division 

2,482,491 3.82 4.70 23.2

Michigan Ann Arbor-FlintcPotentially 

overserved area 

Large MSA 1,039,569 3.49 4.19 20.0

Michigan Grand RapidsMuskegon-Holland Other area Large MSA 1,150,683 2.94 3.52 19.5

Michigan KalamazooBattle Creek Other area Large MSA 459,879 3.00 3.55 18.5

Michigan Lansing-East 

Lansing 

Potentially 

overserved area 

Large MSA 456,440 3.37 3.96 17.6

Page 52 GAO-09-559 Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

State Area name Statusa Type of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Michigan Saginaw-Bay CityMidland Potentially 

overserved area 

Large MSA 392,603 3.45 4.01 16.1

Michigan Small 

metropolitan areas 

Other area Small MSA 

areas 

322,595 3.16 3.67 16.2

Michigan Rural counties Other area Rural areas 1,782,461 3.14 3.68 17.1

Minnesota MinneapolisSt. Paul Other area Large MSA 3,087,504 3.13 3.61 15.4

Minnesota Small 

metropolitan areas 

Other area Small MSA 

areas 

627,054 3.16 3.48 10.4

Minnesota Rural counties Other area Rural areas 1,483,063 2.94 3.37 14.6

Mississippi Biloxi-GulfportPascagoula Other area Large MSA 345,890 3.80 3.92 3.1

Mississippi Jackson Potentially 

overserved area 

Large MSA 476,906 3.29 3.77 14.5

Mississippi Small 

metropolitan areas 

Other area Small MSA 

areas 

275,332 3.65 4.01 9.8

Mississippi Rural counties Other area Rural areas 1,820,657 3.33 3.67 10.2

Missouri Kansas Cityc Other area Large MSA 1,137,909 3.49 3.91 11.9

Missouri Springfield Other area Large MSA 372,973 2.88 3.29 14.1

Missouri St. Louisc Potentially 

overserved area 

Large MSA 2,087,945 3.35 3.96 18.0

Missouri Small 

metropolitan areas 

Other area Small MSA 

areas 

427,062 3.25 3.76 15.6

Missouri Rural counties Other area Rural areas 1,852,526 3.23 3.69 14.1

Montana Small 

metropolitan areas 

Other area Small MSA 

areas 

327,361 3.10 3.47 11.9

Montana Rural counties Other area Rural areas 630,500 3.02 3.25 7.6

Nebraska Lincoln Other area Large MSA 275,665 3.13 3.77 20.4

Nebraska Omaha Potentially 

overserved area 

Large MSA 689,708 3.40 3.96 16.7

Nebraska Small 

metropolitan areas 

Other area Small MSA 

areas 

20,312 3.37 3.23 -4.2

Nebraska Rural counties Other area Rural areas 788,886 3.05 3.47 13.7

Nevada Las Vegas Other area Large MSA 1,880,449 4.09 4.63 13.4

Nevada Reno Other area Large MSA 406,079 3.21 3.63 13.1

Nevada Rural counties Other area Rural areas 278,854 3.10 3.41 10.0

Page 53 GAO-09-559 Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

State Area name Statusa Type of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

New 

Hampshire 

Rockingham 

CountyStrafford County 

Other area Metropolitan 

division 

418,124 3.09 3.61 16.9

New 

Hampshire 

Hillsborough 

Countyc

Other area Large MSA 550,576 3.04 3.43 13.0

New 

Hampshire 

Rural counties Other area Rural areas 347,128 2.85 3.20 12.5

New Jersey Camden Other area Metropolitan 

division 

1,246,339 3.66 4.15 13.4

New Jersey Edison-New 

Brunswick 

Potentially 

overserved area 

Metropolitan 

division 

2,319,704 3.72 4.46 20.0

New Jersey Newark-Union Potentially 

overserved area 

Metropolitan 

division 

2,070,046 3.70 4.47 20.8

New Jersey WaynecPotentially 

overserved area 

Metropolitan 

division 

1,986,019 3.84 4.61 20.0

New Jersey Atlantic Countyc Potentially 

overserved area 

Large MSA 522,610 3.71 4.24 14.2

New Jersey Mercer Countyc Potentially 

overserved area 

Large MSA 475,186 3.70 4.39 18.7

New Jersey Small 

metropolitan areas 

Other area Small MSA 

areas 

66,016 3.73 4.04 8.2

New Mexico Albuquerque Other area Large MSA 818,522 3.02 3.23 6.7

New Mexico Small 

metropolitan areas 

Other area Small MSA 

areas 

360,304 3.09 3.41 10.4

New Mexico Rural counties Other area Rural areas 791,089 3.08 3.30 6.9

New York Nassau-Suffolk Potentially 

overserved area 

Metropolitan 

division 

2,759,762 3.86 4.76 23.2

New York New YorkWhite Plainsc

Potentially 

overserved area 

Metropolitan 

division 

9,621,824 3.91 4.97 27.0

New York AlbanySchenectady-Troy Potentially 

overserved area 

Large MSA 902,053 3.34 3.82 14.4

New York Binghamton Other area Large MSA 246,426 3.17 3.45 9.0

New York BuffaloNiagara Falls Other area Large MSA 1,128,183 3.13 3.55 13.5

New York Orange County Potentially 

overserved area 

Large MSA 669,915 3.43 4.20 22.7

New York Rochester Other area Large MSA 1,088,617 2.87 3.36 17.0

New York Syracuse Other area Large MSA 725,359 3.28 3.60 9.7

New York Utica-Rome Other area Large MSA 294,862 3.15 3.57 13.3

Page 54 GAO-09-559 Medicare Physician Services
Appendix III: Utilization Status of Geographic 

Areas 

Medicare Physician Services

State Area name StatusaType of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

New York Small 

metropolitan areas 

Other area Small MSA 

areas 

350,846 3.24 3.74 15.2

New York Rural counties Other area Rural areas 1,509,882 3.13 3.57 13.9

North Carolina Asheville Other area Large MSA 247,080 3.13 3.28 4.7

North Carolina CharlotteGastoniac

Other area Large MSA 1,628,028 3.20 3.67 14.7

North Carolina Fayetteville Other area Large MSA 306,518 2.96 3.69 24.7

North Carolina Greensboro–

Winston Salem–

High Point 

Other area Large MSA 1,371,125 3.10 3.58 15.2

North Carolina HickoryMorganton-Lenoir Other area Large MSA 360,471 3.05 3.46 13.5

North Carolina RaleighDurhamChapel Hill Other area Large MSA 1,489,897 3.05 3.54 16.1

North Carolina Wilmington Other area Large MSA 289,646 3.37 3.55 5.5

North Carolina Small 

metropolitan areas 

Other area Small MSA 

areas 

657,154 3.19 3.57 12.0

North Carolina Rural counties Other area Rural areas 2,711,113 3.13 3.55 13.3

North Dakota Small 

metropolitan areas 

Other area Small MSA 

areas 

307,807 3.15 3.40 7.9

North Dakota Rural counties Other area Rural areas 331,908 2.98 3.30 10.7

Ohio Canton-Massillon Other area Large MSA 407,180 3.39 3.84 13.1

Ohio Cincinnatic Other area Large MSA 1,642,093 3.16 3.82 20.9

Ohio Cleveland-Akron Potentially 

overserved area 

Large MSA 2,896,968 3.42 4.08 19.6

Ohio Columbus Other area Large MSA 1,672,583 3.33 3.78 13.3

Ohio Dayton-Springfield Other area Large MSA 934,275 3.25 3.93 21.1

Ohio Toledo Potentially 

overserved area 

Large MSA 609,871 3.56 4.07 14.2

Ohio YoungstownWarren Potentially 

overserved area 

Large MSA 562,593 3.50 4.17 19.1

Ohio Small 

metropolitan areas 

Potentially 

overserved area 

Small MSA 

areas 

582,391 3.39 3.90 15.0

Ohio Rural counties Other area Rural areas 2,158,963 3.17 3.70 17.0

Oklahoma Oklahoma City Other area Large MSA 1,179,140 3.32 3.62 8.9

Oklahoma Tulsa Other area Large MSA 850,008 3.24 3.57 10.3

Page 55 GAO-09-559 
Appendix III: Utilization Status of Geographic 

Areas 

Medicare Physician Services

State Area name StatusaType of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Oklahoma Small 

metropolitan areas 

Other area Small MSA 

areas 

212,492 3.30 3.61 9.3

Oklahoma Rural counties Other area Rural areas 1,375,676 3.25 3.46 6.2

Oregon EugeneSpringfield Other area Large MSA 343,591 2.84 3.21 13.3

Oregon Portland-SalemcOther area Large MSA 2,133,034 2.95 3.36 13.9

Oregon Small 

metropolitan areas 

Other area Small MSA 

areas 

280,723 2.91 3.34 15.0

Oregon Rural counties Other area Rural areas 990,107 2.89 3.16 9.4

Pennsylvania Philadelphia Potentially 

overserved area 

Metropolitan 

division 

3,887,694 3.77 4.34 15.2

Pennsylvania AllentownBethlehem-Easton Potentially 

overserved area 

Large MSA 694,107 3.44 3.92 14.0

Pennsylvania Erie Other area Large MSA 279,092 3.26 3.82 17.0

Pennsylvania HarrisburgLebanon-Carlisle Other area Large MSA 656,781 3.28 3.72 13.6

Pennsylvania Johnstown Potentially 

overserved area 

Large MSA 222,856 3.31 3.95 19.6

Pennsylvania Lancaster Other area Large MSA 498,465 3.28 3.74 14.1

Pennsylvania Pittsburgh Potentially 

overserved area 

Large MSA 2,286,653 3.79 4.45 17.2

Pennsylvania Reading Other area Large MSA 401,955 3.19 3.83 20.0

Pennsylvania Scranton– 

Wilkes-Barre–

Hazleton 

Other area Large MSA 614,156 3.47 3.87 11.5

Pennsylvania York Other area Large MSA 421,049 3.06 3.52 15.0

Pennsylvania Small 

metropolitan areas 

Other area Small MSA 

areas 

562,438 3.39 3.66 7.9

Pennsylvania Rural counties Potentially 

overserved area 

Rural areas 1,907,546 3.28 3.76 14.5

Rhode Island ProvidenceWarwickc

Other area Large MSA 1,057,832 3.28 3.73 13.6

South Carolina CharlestonNorth Charleston Other area Large MSA 630,100 3.25 3.67 13.0

South Carolina Columbia Other area Large MSA 601,004 3.26 3.84 17.8

South Carolina GreenvilleSpartanburgAnderson Other area Large MSA 1,053,776 3.09 3.50 13.4

South Carolina Myrtle Beach Other area Large MSA 249,925 3.47 3.73 7.6

Page 56 GAO-09-559 
Appendix III: Utilization Status of Geographic 

Areas 

Medicare Physician Services

State Area name StatusaType of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

South Carolina York CountycOther area Large MSA 208,827 3.08 3.69 19.8

South Carolina Small 

metropolitan areas 

Other area Small MSA 

areas 

413,571 3.28 3.65 11.1

South Carolina Rural counties Other area Rural areas 1,250,506 3.27 3.70 13.0

South Dakota Sioux Falls Other area Large MSA 213,037 3.16 3.71 17.5

South Dakota Small 

metropolitan areas 

Other area Small MSA 

areas 

96,280 3.21 3.30 2.8

South Dakota Rural counties Other area Rural areas 486,897 3.15 3.30 4.9

Tennessee Chattanooga Other area Large MSA 358,306 3.45 3.79 10.0

Tennessee Johnson CityKingsport-Bristol Other area Large MSA 404,127 3.21 3.59 11.8

Tennessee Knoxville Other area Large MSA 765,052 3.39 3.77 11.3

Tennessee Memphis Potentially 

overserved area 

Large MSA 1,004,979 3.94 4.49 14.2

Tennessee Nashville Potentially 

overserved area 

Large MSA 1,436,104 3.28 3.78 15.1

Tennessee Small 

metropolitan areas 

Potentially 

overserved area 

Small MSA 

areas 

267,120 3.40 3.88 14.2

Tennessee Rural counties Other area Rural areas 1,921,031 3.23 3.70 14.7

Texas Dallas-PlanoIrving Other area Metropolitan 

division 

4,106,154 3.73 4.16 11.6

Texas Fort WorthArlington Potentially 

overserved area 

Metropolitan 

division 

1,975,919 3.45 3.98 15.5

Texas Amarillo Other area Large MSA 233,811 3.58 3.90 9.0

Texas AustinSan Marcos Other area Large MSA 1,598,161 3.52 3.87 9.8

Texas BeaumontPort Arthur Other area Large MSA 376,241 3.76 4.24 12.8

Texas BrownsvilleHarlingenSan Benito Potentially 

overserved area 

Large MSA 387,210 4.10 4.66 13.8

Texas Corpus Christi Potentially 

overserved area 

Large MSA 389,655 3.76 4.29 13.9

Texas El Paso Other area Large MSA 734,669 3.64 3.89 6.7

Texas HoustonGalvestonBrazoria Other area Large MSA 5,576,673 4.85 4.80 -1.1

Texas Killeen-Temple Other area Large MSA 349,131 3.33 3.38 1.4

Page 57 GAO-09-559 
Appendix III: Utilization Status of Geographic 

Areas 

Medicare Physician Services

State Area name StatusaType of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Texas Laredo Potentially 

overserved area 

Large MSA 233,152 3.87 4.52 16.7

Texas Longview-Marshall Other area Large MSA 218,547 3.61 3.88 7.3

Texas Lubbock Other area Large MSA 260,901 3.85 4.28 11.1

Texas McAllen-EdinburgMission Potentially 

overserved area 

Large MSA 710,514 4.37 5.06 15.7

Texas Odessa-Midland Other area Large MSA 255,978 3.68 3.37 -8.3

Texas San Antonio Other area Large MSA 1,851,721 3.75 4.25 13.2

Texas Waco Other area Large MSA 228,123 3.18 3.56 12.0

Texas Small 

metropolitan areas 

Other area Small MSA 

areas 

1,164,156 3.55 3.91 10.3

Texas Rural counties Other area Rural areas 3,253,664 3.58 3.96 10.5

Utah Provo-Orem Other area Large MSA 483,702 2.79 3.33 19.5

Utah Salt Lake CityOgden Other area Large MSA 1,519,510 2.88 3.23 11.9

Utah Small 

metropolitan areas 

Other area Small MSA 

areas 

6,523 3.27 3.57 8.9

Utah Rural counties Other area Rural areas 635,595 2.83 3.26 15.3

Vermont Burlington Other area Large MSA 207,361 2.98 3.14 5.4

Vermont Rural counties Other area Rural areas 413,893 2.88 3.13 8.6

Virginia ArlingtonAlexandriac

Other area Metropolitan 

division 

2,443,060 3.47 3.91 12.6

Virginia Lynchburg Other area Large MSA 223,095 2.84 3.36 18.2

Virginia NorfolkVirginia BeachNewport News Other area Large MSA 1,627,705 3.32 3.71 11.8

Virginia RichmondPetersburg Other area Large MSA 1,096,629 3.33 3.58 7.4

Virginia Roanoke Other area Large MSA 240,258 3.10 3.34 7.7

Virginia Small 

metropolitan areas 

Other area Small MSA 

areas 

444,773 3.03 3.38 11.8

Virginia Rural counties Other area Rural areas 1,613,240 3.03 3.36 11.0

Washington Seattle-BellevueEverett Other area Metropolitan 

division 

2,536,182 3.12 3.43 9.8

Washington Tacoma Other area Metropolitan 

division 

773,165 3.04 3.42 12.5

Washington Clark CountycOther area Large MSA 418,070 2.93 3.50 19.5

Page 58 GAO-09-559 
Appendix III: Utilization Status of Geographic 

Areas 

Medicare Physician Services

State Area name StatusaType of areab

Population, 

2007

Services per 

beneficiary 

served, 2000 

Services per 

beneficiary 

served, 2008

Percentage 

change in 

services per 

beneficiary 

served, 2000 

to 2008

Washington RichlandKennewick-Pasco Other area Large MSA 228,992 3.27 3.50 7.1

Washington Spokane Other area Large MSA 456,175 3.00 3.52 17.4

Washington Thurston Countyc Other area Large MSA 556,613 2.94 3.36 14.3

Washington Yakima Other area Large MSA 233,062 2.88 3.28 13.8

Washington Small 

metropolitan areas 

Other area Small MSA 

areas 

192,999 2.90 3.56 22.7

Washington Rural counties Other area Rural areas 1,073,166 2.99 3.29 9.9

West Virginia Charleston Other area Large MSA 246,307 3.51 3.74 6.7

West Virginia Small 

metropolitan areas 

Other area Small MSA 

areas 

530,438 3.35 3.74 11.7

West Virginia Rural counties Other area Rural areas 1,035,290 3.35 3.75 12.0

Wisconsin AppletonOshkosh-Neenah Other area Large MSA 380,180 2.98 3.37 13.0

Wisconsin Green Bay Other area Large MSA 243,132 2.95 3.43 16.3

Wisconsin Madison Other area Large MSA 476,785 2.92 3.32 13.8

Wisconsin Milwaukee-Racine Potentially 

overserved area 

Large MSA 1,739,497 3.29 3.81 15.9

Wisconsin Small 

metropolitan areas 

Other area Small MSA 

areas 

1,000,654 3.12 3.65 16.9

Wisconsin Rural counties Other area Rural areas 1,761,392 2.96 3.38 14.0

Wyoming Small 

metropolitan areas 

Other area Small MSA 

areas 

158,103 3.03 3.58 18.1

Wyoming Rural counties Other area Rural areas 364,727 2.99 3.21 7.4

Source: GAO analysis of U.S. Census Bureau data and Medicare Part B claims data for April 2000 and April 2008 from CMS. 

a

Potentially overserved areas are areas that were in the top half of areas in both utilization of 

physician services in 2000 and growth in utilization of physician services from 2000 to 2008. The rest 

of the areas were designated as other areas. 

b

Counties were mapped to metropolitan divisions based on U.S. Census Bureau designations. 

Counties mapped to MSAs based on U.S. Census Bureau and OMB designations were classified as 

MSA areas. Small MSA areas are MSAs with fewer than 200,000 in population grouped together 

within each state. Rural areas include all rural counties within a state. 

c

Some counties were reassigned to different areas as result of overlap between metropolitan divisions 

and large MSAs or because the original entity crossed state lines. The revised areas were renamed 

after the remaining municipalities in the area or the largest county in the area. 

Page 59 GAO-09-559 
Appendix IV: Selected Physician Services in Appendix IV: Selected Physician Services in Potentially Overserved and Other Areas 

Potentially Overserved and Other Areas 

Using the BETOS code to which each procedure code in our claims data 

was assigned, we reviewed specific categories of physician services.1

 We 

collapsed data on other services and procedures into summary categories. 

We classified geographic areas of the country by type of area and 

utilization status. Our measure of utilization—services per beneficiary 

served—is based on Medicare claims data for services performed in the 

first 28 days of April 2000 and April 2008. An area was designated as 

potentially overserved if it was in both the top half of all areas in number 

of services per beneficiary served in 2000 and in the top half of the growth 

rate in services per beneficiary served from 2000 to 2008. Table 13 shows 

the specific service categories we reviewed, the change in the number of 

services provided per 1,000 FFS beneficiaries from April 2000 to April 

2008, and the number of and difference in services provided in potentially 

overserved and other areas. 

 

1

According to 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. 

Page 60 GAO-09-559 Medicare Physician Services 
Appendix IV: Selected Physician Services in 

Potentially Overserved and Other Areas 

Table 13: Selected Physician Services Provided per 1,000 Medicare FFS Beneficiaries in Potentially Overserved Areas and 

Other Areas 

Service category 

Percentage 

change from 2000 

to 2008 in services 

per 1,000 Medicare 

FFS beneficiaries

Services per 1,000 

Medicare 

FFS beneficiaries 

in potentially 

overserved areas, 2008

Services per 1,000 

Medicare 

FFS beneficiaries in 

other areas, 2008 

Percentage 

difference in 

services per 1,000 

Medicare FFS 

beneficiaries in 

potentially 

overserved and 

other areas, 2008

All evaluation and management 15.1 1,229.2 948.1 29.7

Office visits-new patients 6.4 34.8 28.5 22.1

Office visits-established patients 14.1 566.6 474.4 19.4

Hospital visits 28.7 297.9 211.8 40.7

Emergency room visits 14.1 40.3 38.8 3.7

All imaging 41.4 457.4 386.5 18.3

CT scans 94.2 58.0 49.5 17.2

MRIs 116.4 16.9 14.8 14.7

Endoscopy 20.8 26.2 22.2 18.0

Lab tests 548.2 45.1 34.6 30.6

Other tests 26.7 166.1 121.4 36.7

All major procedures -9.5 24.2 22.5 7.4

Major cardiac procedures -22.9 12.1 10.6 14.5

Major orthopedic procedures 25.7 3.9 4.1 -4.8

Minor procedures 37.3 208.3 130.9 59.2

Ambulatory procedures 73.7 67.5 51.5 31.2

Eye procedures 28.5 13.4 12.0 12.0

Anesthesia 16.8 22.6 16.5 36.6

Oncology 10.2 34.3 26.4 29.9

All services 25.7 2,314.7 1,788.9 29.4

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

Note: Potentially overserved areas are areas that were in the top half of areas in both utilization of 

physician services in 2000 and growth in utilization of physician services from 2000 to 2008. The rest 

of the areas were designated as other areas. 

Page 61 GAO-09-559 Medicare Physician Services
Appendix V: Utilization Status of Medicare Appendix V: Utilization Status of Medicare Physician Payment Localities 

Physician Payment Localities 

Medicare designates 87 distinct physician payment localities across the 50 

states and the District of Columbia to adjust physician payments for the 

geographic difference in the costs of operating a private medical practice.1

We measured utilization in each of the Medicare physician payment 

localities by examining the number of services per beneficiary who 

received services in April 2000 and April 2008, and ranked each payment 

locality by the level of utilization in 2000 and the change in utilization from 

2000 to 2008. To determine a locality’s utilization status, we designated 

Medicare physician payment localities in the top half of both measures as 

potentially overserved payment localities and designated the rest as other 

payment localities. Across all Medicare physician payment localities, the 

median number of services per beneficiary served was 3.34 in 2000 and 

3.81 in 2008. The median percentage change in services per beneficiary 

served from 2000 to 2008 was 13.4 percent. (See table 14.) 

 

1

There are 89 Medicare physician payment localities across the United States and 

surrounding territories. We excluded the Medicare physician payment localities for the U.S. 

Virgin Islands and Puerto Rico from our analysis. 

Page 62 GAO-09-559 Medicare Physician Services 
Appendix V: Utilization Status of Medicare 

Physician Payment Localities 

Table 14: Utilization Status of Medicare Physician Payment Localities 

Locality name Status 

Services 

per beneficiary 

served, 2000

Services 

per beneficiary 

served, 2008 

Percentage change 

in services 

per beneficiary 

served, 2000 to 2008

Alaska Other payment locality 3.30 3.43 4.0

Alabama Potentially overserved 

payment locality 

3.36 3.84 14.2

Arkansas Other payment locality 3.36 3.73 11.1

Arizona Potentially overserved 

payment locality 

3.47 4.03 16.2

Anaheim/Santa Ana, CA Other payment locality 3.98 4.37 9.6

Los Angeles, CA Other payment locality 4.48 4.63 3.4

Marin/Napa/Solano, CA Other payment locality 3.13 3.71 18.3

Oakland/Berkley, CA Other payment locality 3.23 3.76 16.5

Rest of California Other payment locality 3.35 3.72 11.1

San Francisco, CA Other payment locality 3.16 3.52 11.2

San Mateo, CA Other payment locality 3.15 3.74 18.9

Santa Clara, CA Other payment locality 3.01 3.52 16.7

Ventura, CA Other payment locality 3.75 4.08 8.8

Colorado Other payment locality 3.12 3.58 14.7

Connecticut Other payment locality 3.16 3.81 20.8

DC and MD/VA suburbs Other payment locality 3.69 4.07 10.3

Delaware Other payment locality 3.29 3.87 17.6

Fort Lauderdale, FL Potentially overserved 

payment locality 

4.03 4.87 20.9

Miami, FL Potentially overserved 

payment locality 

4.49 5.10 13.6

Rest of Florida Potentially overserved 

payment locality 

3.61 4.29 19.1

Atlanta, GA Other payment locality 3.34 3.90 16.5

Rest of Georgia Other payment locality 3.22 3.65 13.4

Hawaii/Guam Other payment locality 3.01 3.25 8.0

Iowa Other payment locality 3.14 3.45 9.6

Idaho Other payment locality 2.90 3.15 8.9

Chicago, IL Potentially overserved 

payment locality 

3.79 4.55 20.0

East St. Louis, IL Other payment locality 3.35 3.80 13.3

Rest of Illinois Other payment locality 3.27 3.82 16.7

Page 63 GAO-09-559 Medicare Physician Services
Appendix V: Utilization Status of Medicare 

Physician Payment Localities 

Locality name Status 

Services 

per beneficiary 

served, 2000

Services 

per beneficiary 

served, 2008 

Percentage change 

in services 

per beneficiary 

served, 2000 to 2008

Suburban Chicago, IL Potentially overserved 

payment locality 

3.50 4.34 24.0

Indiana Other payment locality 3.15 3.71 17.7

Kansas Other payment locality 3.23 3.61 11.8

Kentucky Potentially overserved 

payment locality 

3.34 3.84 15.0

New Orleans, LA Other payment locality 3.79 4.18 10.4

Rest of Louisiana Other payment locality 3.57 3.98 11.4

Metropolitan Boston Other payment locality 3.47 3.81 9.8

Rest of Massachusetts Other payment locality 3.27 3.69 12.8

Baltimore/surrounding 

counties, MD 

Other payment locality 3.48 3.90 11.9

Rest of Maryland Other payment locality 3.40 3.81 12.1

Rest of Maine Other payment locality 3.03 3.20 5.7

Southern Maine Other payment locality 3.12 3.37 8.1

Detroit, MI Potentially overserved 

payment locality 

3.84 4.73 23.1

Rest of Michigan Other payment locality 3.21 3.82 18.9

Minnesota Other payment locality 3.05 3.50 14.7

Metropolitan Kansas City, MO Other payment locality 3.52 3.92 11.5

Metropolitan St. Louis, MO Potentially overserved 

payment locality 

3.37 3.97 17.6

Rest of Missouri Other payment locality 3.20 3.68 14.9

Mississippi Other payment locality 3.40 3.74 10.0

Montana Other payment locality 3.05 3.33 9.1

North Carolina Other payment locality 3.13 3.56 13.6

North Dakota Other payment locality 3.04 3.34 9.9

Nebraska Other payment locality 3.15 3.66 16.0

New Hampshire Other payment locality 2.99 3.42 14.4

Northern New Jersey Potentially overserved 

payment locality 

3.78 4.53 19.9

Rest of New Jersey Potentially overserved 

payment locality 

3.67 4.31 17.3

New Mexico Other payment locality 3.07 3.30 7.6

Nevada Other payment locality 3.75 4.25 13.2

Manhattan, NY Potentially overserved 

payment locality 

3.83 4.50 17.6

Page 64 GAO-09-559 Medicare Physician Services
Appendix V: Utilization Status of Medicare 

Physician Payment Localities 

Locality name Status 

Services 

per beneficiary 

served, 2000

Services 

per beneficiary 

served, 2008 

Percentage change 

in services 

per beneficiary 

served, 2000 to 2008

NYC suburbs/Long Island, NY Potentially overserved 

payment locality 

3.93 4.94 25.5

Poughkeepsie/ Northern NYC 

suburbs, NY 

Potentially overserved 

payment locality 

3.37 4.09 21.5

Queens, NY Potentially overserved 

payment locality 

3.82 5.08 33.2

Rest of New York Other payment locality 3.16 3.56 12.9

Ohio Other payment locality 3.32 3.91 17.8

Oklahoma Other payment locality 3.27 3.53 7.9

Portland, OR Other payment locality 2.96 3.37 13.7

Rest of Oregon Other payment locality 2.89 3.22 11.5

Metropolitan Philadelphia, PA Potentially overserved 

payment locality 

3.77 4.34 15.2

Rest of Pennsylvania Other payment locality 3.43 3.88 13.2

Rhode Island Other payment locality 3.28 3.73 13.6

South Carolina Other payment locality 3.23 3.66 13.5

South Dakota Other payment locality 3.16 3.39 7.3

Tennessee Potentially overserved 

payment locality 

3.37 3.83 13.5

Austin, TX Other payment locality 3.53 3.94 11.6

Beaumont, TX Potentially overserved 

payment locality 

3.74 4.25 13.4

Brazoria, TX Potentially overserved 

payment locality 

3.82 4.36 14.0

Dallas, TX Other payment locality 3.80 4.13 8.7

Fort Worth, TX Potentially overserved 

payment locality 

3.46 3.99 15.4

Galveston, TX Other payment locality 4.12 4.57 10.8

Houston, TX Other payment locality 5.12 4.91 -4.1

Rest of Texas Other payment locality 3.67 4.10 11.5

Utah Other payment locality 2.86 3.25 13.8

Virginia Other payment locality 3.16 3.53 11.8

Vermont Other payment locality 2.91 3.13 7.7

Rest of Washington Other payment locality 3.00 3.40 13.3

Seattle (King County), WA Other payment locality 3.13 3.41 8.8

Wisconsin Other payment locality 3.09 3.57 15.5

West Virginia Other payment locality 3.37 3.75 11.1

Page 65 GAO-09-559 Medicare Physician Services
Appendix V: Utilization Status of Medicare 

Physician Payment Localities 

Locality name Status 

Services 

per beneficiary 

served, 2000

Services 

per beneficiary 

served, 2008 

Percentage change 

in services 

per beneficiary 

served, 2000 to 2008

Wyoming Other payment locality 3.00 3.34 11.1

Source: GAO analysis of Medicare Part B claims data, enrollment data, and physician payment locality data from CMS. 

Notes: Potentially overserved Medicare physician payment localities are localities that were in the top 

half of localities in both utilization of physician services in 2000 and growth in utilization of physician 

services from 2000 to 2008. The rest of the Medicare physician localities were designated as other 

payment localities. We combined certain Medicare physician payment localities in California, Kansas, 

and Missouri. We excluded data from the Puerto Rico and U.S. Virgin Islands Medicare physician 

payment localities. 

Page 66 GAO-09-559 Medicare Physician Services
Appendix VI: Selected Physician Services in 

Potentially Overserved and Other Medicare Appendix VI: Selected Physician Services in Physician Payment Localities 

Potentially Overserved and Other Medicare 

Physician Payment Localities 

Using the BETOS code to which each procedure code in our claims data 

was assigned, we reviewed specific categories of physician services.1

 We 

collapsed data on other services and procedures into summary categories. 

We classified Medicare physician payment localities by utilization status. 

Our measure of utilization—services per beneficiary served—is based on 

Medicare claims data for services performed in the first 28 days of April 

2000 and April 2008.2

 A Medicare physician payment locality was 

designated as potentially overserved if it was in both the top half of all 

areas in number of services per beneficiary served in 2000 and in the top 

half of the growth rate in services per beneficiary served from 2000 to 

2008. Table 15 shows the specific service categories we reviewed, the 

change in the number of services provided per 1,000 FFS beneficiaries 

from April 2000 to April 2008, and the number of and difference in services 

provided in potentially overserved and other Medicare physician payment 

localities. 

 

1

According to 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. 

2

Physician payment localities are the 87 distinct geographic regions designated by Medicare 

among which physician payments are adjusted for the costs of operating a private medical 

practice in each locality. 

Page 67 GAO-09-559 Medicare Physician Services 
Appendix VI: Selected Physician Services in 

Potentially Overserved and Other Medicare 

Physician Payment Localities 

Table 15: Selected Physician Services Provided per 1,000 Medicare FFS Beneficiaries in Potentially Overserved and Other 

Medicare Physician Payment Localities 

Service category 

Percentage change 

from 2000 to 2008 

in services 

per 1,000 Medicare 

FFS beneficiaries

Services 

per 1,000 Medicare 

FFS beneficiaries 

in potentially 

overserved payment 

localities, 2008

Services 

per 1,000 Medicare 

FFS beneficiaries 

in other payment 

localities, 2008 

Percentage difference 

in services 

per 1,000 Medicare 

FFS beneficiaries in 

potentially overserved 

and other payment 

localities, 2008

All evaluation 

and management 15.1 1,243.4 961.2 29.4

Office visits-new patients 6.4 35.6 28.6 24.5

Office visits-established 

patients 14.1 579.1 475.6 21.8

Hospital visits 28.7 295.6 218.3 35.4

Emergency room visits 14.1 40.0 39.0 2.6

All imaging 41.4 458.0 391.0 17.1

CT scans 94.2 58.0 50.1 15.8

MRIs 116.4 17.3 14.7 17.6

Endoscopy 20.8 26.4 22.4 17.9

Lab tests 548.2 43.6 35.8 21.8

Other tests 26.7 168.6 123.4 36.6

All major procedures -9.5 24.0 22.7 5.7

Major cardiac procedures -22.9 12.0 10.7 12.5

Major orthopedic procedures 25.7 3.9 4.1 -5.3

Minor procedures 37.3 212.8 134.3 58.4

Ambulatory procedures 73.7 69.3 51.9 33.6

Eye procedures 28.5 13.6 12.0 12.9

Anesthesia 16.8 22.2 17.1 29.9

Oncology 10.2 34.1 27.0 26.5

All services 25.7 2,337.0 1,815.0 28.8

Source: GAO analysis of Medicare Part B claims data, enrollment data, and physician payment locality data from CMS. 

Notes: Potentially overserved Medicare physician payment localities are localities that were in the top 

half of localities in both utilization of physician services in 2000 and growth in utilization of physician 

services from 2000 to 2008. The rest of the localities were designated as other Medicare physician 

payment localities. We combined certain Medicare physician payment localities in California, Kansas, 

and Missouri. We excluded data from the Puerto Rico and U.S. Virgin Islands Medicare physician 

payment localities. 

Page 68 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital Appendix VII: Utilization Status of Hospital Referral Regions 

Referral Regions 

Hospital referral regions (HRR) are the 306 distinct geographic regions 

designated by Dartmouth researchers to represent regional health care 

markets for tertiary medical care. Each HRR contains at least one hospital 

that performs major cardiovascular procedures and neurosurgery. We 

measured utilization in each of the HRRs by examining the number of 

services per beneficiary who received services in April 2000 and April 

2008, and ranked each HRR by level of utilization in 2000 and change in 

utilization from 2000 to 2008. To determine an HRR’s utilization status, we 

designated HRRs in the top half of both measures as potentially 

overserved HRRs and designated the rest as other HRRs. Across all HRRs, 

the median number of services per beneficiary served was 3.26 in 2000 and 

3.72 in 2008. The median percentage change in services per beneficiary 

served from 2000 to 2008 was 13.7 percent. (See table 16.) 

Page 69 GAO-09-559 Medicare Physician Services 
Appendix VII: Utilization Status of Hospital 

Referral Regions 

Table 16: Utilization Status of Hospital Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

Birmingham, ALa Potentially overserved HRR 3.37 3.85 14.3

Dothan, ALa Other HRR 3.28 3.69 12.6

Huntsville, ALaOther HRR 3.24 3.81 17.4

Mobile, ALaOther HRR 3.58 4.00 11.9

Montgomery, AL Other HRR 3.26 3.69 13.1

Tuscaloosa, AL Other HRR 3.55 4.03 13.6

Anchorage, AK Other HRR 3.30 3.43 3.9

Mesa, AZ Potentially overserved HRR 3.48 4.06 16.8

Phoenix, AZaPotentially overserved HRR 3.50 4.06 16.1

Sun City, AZ Potentially overserved HRR 3.65 4.29 17.5

Tucson, AZ Other HRR 3.25 3.86 18.6

Fort Smith, ARaOther HRR 3.36 3.60 7.2

Jonesboro, ARa Other HRR 3.28 3.72 13.3

Little Rock, AR Other HRR 3.38 3.78 11.7

Springdale, ARa Other HRR 3.21 3.53 10.0

Texarkana, ARaOther HRR 3.32 3.58 7.8

Orange County, CA Other HRR 3.98 4.36 9.5

Bakersfield, CA Potentially overserved HRR 3.35 3.95 17.7

Chico, CA Other HRR 3.08 3.44 11.9

Contra Costa County, CA Other HRR 3.21 3.99 24.2

Fresno, CA Other HRR 3.11 3.65 17.4

Los Angeles, CA Other HRR 4.48 4.64 3.5

Modesto, CA Other HRR 3.13 3.56 13.7

Napa, CA Other HRR 3.24 3.54 9.3

Alameda County, CA Other HRR 3.23 3.59 11.2

Palm Springs/Rancho Mira, CA Other HRR 3.77 4.07 7.8

Redding, CA Other HRR 3.32 3.43 3.3

Sacramento, CAaOther HRR 3.17 3.48 9.8

Salinas, CA Other HRR 3.29 3.54 7.5

San Bernardino, CA Other HRR 3.73 4.07 9.2

San Diego, CA Other HRR 3.59 3.97 10.7

San Francisco, CA Other HRR 3.16 3.59 13.8

San Jose, CA Other HRR 3.02 3.53 17.1

San Luis Obispo, CA Other HRR 3.08 3.47 12.7

Page 70 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital 

Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

San Mateo County, CA Other HRR 3.13 3.71 18.3

Santa Barbara, CA Other HRR 3.42 3.64 6.4

Santa Cruz, CA Other HRR 3.21 3.59 11.9

Santa Rosa, CA Other HRR 3.10 3.55 14.7

Stockton, CA Other HRR 3.18 3.48 9.4

Ventura, CA Other HRR 3.76 4.08 8.4

Boulder, CO Potentially overserved HRR 3.50 4.07 16.3

Colorado Springs, COaOther HRR 3.02 3.56 17.8

Denver, COaOther HRR 3.21 3.69 14.9

Fort Collins, COaOther HRR 2.98 3.44 15.5

Grand Junction, COaOther HRR 2.71 3.11 15.1

Greeley, COa Other HRR 3.00 3.34 11.4

Pueblo, CO Other HRR 3.08 3.40 10.2

Bridgeport, CT Potentially overserved HRR 3.41 4.18 22.5

Hartford, CTaOther HRR 3.00 3.62 20.7

New Haven, CTaOther HRR 3.24 3.89 20.2

Wilmington, DEaPotentially overserved HRR 3.34 3.97 19.0

Washington, DCaOther HRR 3.62 3.95 9.2

Bradenton, FL Potentially overserved HRR 3.61 4.54 25.7

Clearwater, FL Potentially overserved HRR 3.70 4.42 19.5

Fort Lauderdale, FL Potentially overserved HRR 4.18 5.05 20.7

Fort Myers, FL Potentially overserved HRR 3.74 4.57 22.1

Gainesville, FL Potentially overserved HRR 3.52 4.02 14.4

Hudson, FL Potentially overserved HRR 3.87 4.60 18.9

Jacksonville, FLaPotentially overserved HRR 3.73 4.46 19.4

Lakeland, FL Potentially overserved HRR 3.46 4.12 19.1

Miami, FL Potentially overserved HRR 4.43 5.09 14.8

Ocala, FL Potentially overserved HRR 3.49 4.01 14.9

Orlando, FL Potentially overserved HRR 3.65 4.38 20.1

Ormond Beach, FL Other HRR 3.23 4.06 25.5

Panama City, FL Potentially overserved HRR 3.53 4.16 17.9

Pensacola, FLa Potentially overserved HRR 3.32 3.83 15.6

Sarasota, FL Potentially overserved HRR 3.61 4.26 18.1

St. Petersburg, FL Potentially overserved HRR 3.71 4.55 22.8

Tallahassee, FLa Other HRR 3.19 3.57 11.9

Tampa, FL Potentially overserved HRR 3.72 4.38 17.7

Page 71 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital 

Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

Albany, GA Other HRR 3.24 3.41 5.2

Atlanta, GAaOther HRR 3.24 3.78 16.5

Augusta, GAaOther HRR 3.21 3.48 8.6

Columbus, GAaOther HRR 3.05 3.53 15.9

Macon, GA Other HRR 3.20 3.78 18.1

Rome, GAaOther HRR 3.10 3.66 17.9

Savannah, GAaOther HRR 3.42 3.79 10.7

Honolulu, HI Other HRR 3.01 3.25 8.0

Boise, IDaOther HRR 2.90 3.15 8.7

Idaho Falls, ID Other HRR 2.94 3.19 8.5

Aurora, IL Potentially overserved HRR 3.29 3.96 20.4

Blue Island, IL Potentially overserved HRR 3.70 4.56 23.0

Chicago, IL Potentially overserved HRR 4.05 4.75 17.2

Elgin, IL Potentially overserved HRR 3.47 4.42 27.6

Evanston, IL Potentially overserved HRR 3.48 4.27 22.7

Hinsdale, IL Potentially overserved HRR 3.51 4.22 20.3

Joliet, IL Potentially overserved HRR 3.73 4.48 20.1

Melrose Park, IL Potentially overserved HRR 3.52 4.26 20.9

Peoria, IL Other HRR 3.16 3.68 16.6

Rockford, IL Other HRR 3.13 3.82 21.9

Springfield, ILa Other HRR 3.41 3.86 13.4

Urbana, ILaOther HRR 3.33 3.72 11.8

Bloomington, IL Other HRR 3.19 3.72 16.4

Evansville, INa Other HRR 3.14 3.63 15.5

Fort Wayne, INaOther HRR 2.96 3.57 20.4

Gary, INaPotentially overserved HRR 3.51 4.24 20.8

Indianapolis, INaOther HRR 3.13 3.57 14.2

Lafayette, IN Other HRR 2.98 3.65 22.4

Muncie, INa Other HRR 3.18 3.61 13.8

Munster, INaPotentially overserved HRR 3.61 4.65 28.7

South Bend, INaOther HRR 2.99 3.52 17.8

Terre Haute, INa Potentially overserved HRR 3.32 3.87 16.4

Cedar Rapids, IA Other HRR 3.08 3.38 9.5

Davenport, IAaOther HRR 3.22 3.73 15.8

Des Moines, IAa Other HRR 3.22 3.52 9.3

Dubuque, IAaOther HRR 2.97 3.22 8.4

Page 72 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital 

Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

Iowa City, IAa

Other HRR 2.95 3.26 10.3

Mason City, IA Other HRR 3.03 3.24 7.1

Sioux City, IAaOther HRR 3.18 3.36 5.6

Waterloo, IA Other HRR 3.22 3.64 13.2

Topeka, KS Other HRR 2.93 3.44 17.5

Wichita, KSaOther HRR 3.23 3.58 10.9

Covington, KYaOther HRR 3.25 4.13 27.1

Lexington, KYaOther HRR 3.19 3.78 18.5

Louisville, KYaOther HRR 3.48 3.94 13.0

Owensboro, KYaOther HRR 3.46 3.64 5.3

Paducah, KYaOther HRR 3.21 3.68 14.9

Alexandria, LA Other HRR 3.37 3.82 13.4

Baton Rouge, LAaOther HRR 3.68 4.08 10.8

Houma, LA Potentially overserved HRR 3.40 3.92 15.2

Lafayette, LA Other HRR 3.50 3.88 10.9

Lake Charles, LAaOther HRR 3.56 3.62 1.6

Metairie, LA Potentially overserved HRR 3.68 4.29 16.7

Monroe, LA Other HRR 3.85 4.19 8.9

New Orleans, LA Other HRR 3.83 4.16 8.8

Shreveport, LAaOther HRR 3.54 3.98 12.4

Slidell, LAa Other HRR 3.72 4.04 8.7

Bangor, ME Other HRR 3.10 3.23 4.2

Portland, MEaOther HRR 3.03 3.30 8.9

Baltimore, MD Other HRR 3.47 3.90 12.3

Salisbury, MDaOther HRR 3.36 3.81 13.4

Takoma Park, MD Other HRR 3.72 4.15 11.5

Boston, MAaOther HRR 3.42 3.79 10.9

Springfield, MAaOther HRR 3.10 3.47 11.8

Worcester, MA Other HRR 3.22 3.62 12.5

Ann Arbor, MI Potentially overserved HRR 3.50 4.11 17.3

Dearborn, MI Potentially overserved HRR 3.78 4.73 25.1

Detroit, MI Potentially overserved HRR 3.94 4.85 23.2

Flint, MI Potentially overserved HRR 3.64 4.43 21.7

Grand Rapids, MI Other HRR 2.97 3.59 20.9

Kalamazoo, MI Other HRR 3.01 3.52 16.8

Lansing, MI Potentially overserved HRR 3.28 3.88 18.4

Page 73 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital 

Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

Marquette, MIa

Other HRR 3.03 3.35 10.5

Muskegon, MI Other HRR 2.98 3.38 13.2

Petoskey, MI Other HRR 3.07 3.89 26.9

Pontiac, MI Potentially overserved HRR 3.76 4.69 24.6

Royal Oak, MI Potentially overserved HRR 3.86 4.83 25.4

Saginaw, MI Potentially overserved HRR 3.40 3.98 17.0

St. Joseph, MI Other HRR 2.98 3.63 21.8

Traverse City, MI Other HRR 3.21 3.59 12.1

Duluth, MNaOther HRR 2.96 3.34 12.8

Minneapolis, MNaOther HRR 3.02 3.52 16.7

Rochester, MNaOther HRR 3.34 3.56 6.5

St. Cloud, MN Other HRR 3.04 3.48 14.5

St. Paul, MNaOther HRR 3.09 3.53 14.5

Gulfport, MS Other HRR 3.80 3.88 2.0

Hattiesburg, MS Other HRR 3.50 3.79 8.3

Jackson, MSaOther HRR 3.27 3.65 11.6

Meridian, MSaOther HRR 3.46 3.74 8.0

Oxford, MS Other HRR 3.34 3.59 7.4

Tupelo, MSa Other HRR 3.06 3.45 12.7

Cape Girardeau, MOaOther HRR 3.21 3.74 16.4

Columbia, MOa Potentially overserved HRR 3.27 3.76 14.9

Joplin, MOaOther HRR 3.17 3.58 13.0

Kansas City, MOaOther HRR 3.47 3.86 11.1

Springfield, MOa Other HRR 3.02 3.46 14.4

St. Louis, MOaPotentially overserved HRR 3.36 3.89 15.9

Billings, MTaOther HRR 3.01 3.21 6.5

Great Falls, MT Other HRR 3.18 3.66 15.2

Missoula, MTaOther HRR 3.04 3.30 8.5

Lincoln, NEa Other HRR 3.06 3.55 16.0

Omaha, NEaOther HRR 3.24 3.75 15.6

Las Vegas, NVaOther HRR 4.06 4.56 12.2

Reno, NVa Other HRR 3.14 3.50 11.3

Lebanon, NHaOther HRR 2.84 3.12 9.9

Manchester, NH Other HRR 3.01 3.45 14.6

Camden, NJ Potentially overserved HRR 3.66 4.31 17.6

Hackensack, NJaPotentially overserved HRR 3.80 4.60 21.0

Page 74 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital 

Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

Morristown, NJa

Potentially overserved HRR 3.54 4.24 19.6

New Brunswick, NJ Potentially overserved HRR 3.85 4.54 17.7

Newark, NJ Potentially overserved HRR 3.92 4.77 21.7

Paterson, NJ Potentially overserved HRR 3.65 4.40 20.5

Ridgewood, NJa Potentially overserved HRR 3.77 4.51 19.6

Albuquerque, NMaOther HRR 3.01 3.18 5.9

Albany, NYaPotentially overserved HRR 3.29 3.88 17.9

Binghamton, NYaOther HRR 3.09 3.40 9.8

Bronx, NY Potentially overserved HRR 3.90 4.70 20.6

Buffalo, NYaOther HRR 3.13 3.57 14.2

Elmira, NYaOther HRR 3.17 3.63 14.3

East Long Island, NY Potentially overserved HRR 3.84 4.86 26.3

Manhattan, NY Potentially overserved HRR 4.00 5.13 28.5

Rochester, NY Other HRR 2.88 3.29 14.3

Syracuse, NY Other HRR 3.23 3.57 10.5

White Plains, NY Potentially overserved HRR 3.77 4.44 17.8

Asheville, NC Other HRR 3.06 3.29 7.5

Charlotte, NCaOther HRR 3.16 3.65 15.3

Durham, NCa Other HRR 3.06 3.56 16.4

Greensboro, NC Other HRR 3.12 3.47 11.5

Greenville, NC Other HRR 3.23 3.59 11.3

Hickory, NC Other HRR 3.07 3.45 12.1

Raleigh, NC Other HRR 3.12 3.64 16.6

Wilmington, NC Other HRR 3.32 3.57 7.6

Winston-Salem, NCaOther HRR 3.10 3.60 16.1

Bismarck, NDaOther HRR 3.18 3.36 5.8

Fargo, NDaOther HRR 2.91 3.26 12.0

Grand Forks, NDaOther HRR 3.00 3.49 16.1

Minot, NDa Other HRR 2.94 3.28 11.7

Akron, OH Potentially overserved HRR 3.39 3.88 14.6

Canton, OH Potentially overserved HRR 3.29 3.77 14.8

Cincinnati, OHa Other HRR 3.16 3.79 20.0

Cleveland, OH Potentially overserved HRR 3.41 4.11 20.6

Columbus, OHaOther HRR 3.25 3.72 14.5

Dayton, OH Potentially overserved HRR 3.26 3.95 21.1

Elyria, OH Potentially overserved HRR 3.43 4.16 21.1

Page 75 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital 

Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

Kettering, OH Other HRR 3.08 3.85 25.2

Toledo, OHaPotentially overserved HRR 3.46 3.97 14.7

Youngstown, OHaPotentially overserved HRR 3.53 4.19 18.7

Lawton, OK Other HRR 3.18 3.57 12.1

Oklahoma City, OKa Other HRR 3.26 3.56 9.2

Tulsa, OKaOther HRR 3.25 3.44 5.8

Bend, OR Other HRR 2.92 3.40 16.8

Eugene, OR Other HRR 2.89 3.20 10.5

Medford, ORaOther HRR 2.89 3.21 11.1

Portland, ORaOther HRR 2.94 3.32 13.0

Salem, OR Other HRR 2.91 3.32 14.2

Allentown, PAa Potentially overserved HRR 3.49 3.98 14.3

Altoona, PA Other HRR 3.33 3.78 13.3

Danville, PA Other HRR 3.08 3.42 10.8

Erie, PAaOther HRR 3.25 3.72 14.7

Harrisburg, PAaOther HRR 3.24 3.68 13.4

Johnstown, PA Potentially overserved HRR 3.31 3.96 19.9

Lancaster, PA Potentially overserved HRR 3.33 3.82 14.9

Philadelphia, PAa Potentially overserved HRR 3.76 4.35 15.6

Pittsburgh, PAaPotentially overserved HRR 3.72 4.30 15.7

Reading, PA Potentially overserved HRR 3.27 3.86 17.9

Sayre, PAaOther HRR 3.14 3.60 14.6

Scranton, PAaOther HRR 3.46 3.86 11.3

Wilkes-Barre, PA Other HRR 3.47 3.94 13.4

York, PA Other HRR 3.03 3.51 15.9

Providence, RIaOther HRR 3.26 3.72 13.9

Charleston, SCaOther HRR 3.32 3.69 11.3

Columbia, SC Other HRR 3.22 3.74 15.9

Florence, SCa Other HRR 3.45 3.77 9.3

Greenville, SC Other HRR 3.12 3.55 13.9

Spartanburg, SCaOther HRR 3.07 3.44 12.1

Rapid City, SDa Other HRR 3.12 3.16 1.2

Sioux Falls, SDaOther HRR 3.08 3.37 9.2

Chattanooga, TNaOther HRR 3.40 3.80 11.8

Jackson, TN Other HRR 3.26 3.80 16.7

Johnson City, TNaOther HRR 3.28 3.66 11.8

Page 76 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital 

Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

Kingsport, TNa

Other HRR 3.05 3.39 11.0

Knoxville, TNaOther HRR 3.30 3.71 12.4

Memphis, TNaPotentially overserved HRR 3.71 4.23 14.2

Nashville, TNaOther HRR 3.28 3.71 13.1

Abilene, TX Other HRR 3.62 3.86 6.7

Amarillo, TXaOther HRR 3.50 3.83 9.3

Austin, TX Other HRR 3.52 3.88 10.2

Beaumont, TX Other HRR 3.79 4.20 10.9

Bryan, TX Other HRR 3.49 3.80 9.0

Corpus Christi, TX Other HRR 3.81 4.28 12.4

Dallas, TXaOther HRR 3.68 4.11 11.7

El Paso, TXa Other HRR 3.50 3.78 7.9

Fort Worth, TX Potentially overserved HRR 3.41 3.93 15.2

Harlingen, TX Potentially overserved HRR 4.12 4.74 15.1

Houston, TX Other HRR 4.55 4.67 2.6

Longview, TX Other HRR 3.60 3.83 6.4

Lubbock, TXaOther HRR 3.69 3.98 7.8

McAllen, TX Potentially overserved HRR 4.45 5.11 15.0

Odessa, TX Other HRR 3.65 3.40 -6.9

San Angelo, TX Other HRR 3.17 3.76 18.5

San Antonio, TX Other HRR 3.70 4.20 13.6

Temple, TX Other HRR 3.38 3.47 2.5

Tyler, TX Other HRR 3.70 3.96 6.9

Victoria, TX Other HRR 3.69 4.07 10.1

Waco, TX Other HRR 3.26 3.58 9.9

Wichita Falls, TXaOther HRR 3.69 3.99 8.1

Ogden, UT Other HRR 2.77 3.31 19.5

Provo, UT Other HRR 2.80 3.29 17.3

Salt Lake City, UTa Other HRR 2.89 3.20 10.8

Burlington, VTaOther HRR 3.05 3.29 8.0

Arlington, VAaOther HRR 3.50 3.91 11.7

Charlottesville, VAa Other HRR 2.84 3.20 12.4

Lynchburg, VA Other HRR 2.81 3.33 18.4

Newport News, VA Other HRR 3.18 3.52 10.9

Norfolk, VAa Other HRR 3.34 3.75 12.5

Richmond, VA Other HRR 3.30 3.61 9.1

Page 77 GAO-09-559 Medicare Physician Services
Appendix VII: Utilization Status of Hospital 

Referral Regions 

HRR name Status 

Services per 

beneficiary 

served, 2000

Services per 

beneficiary 

served, 2008 

Percentage change in 

services per beneficiary 

served, 2000 to 2008

Roanoke, VAa

Other HRR 3.18 3.43 7.6

Winchester, VAaOther HRR 3.10 3.41 9.9

Everett, WA Other HRR 2.95 3.33 12.9

Olympia, WA Other HRR 2.85 3.30 15.7

Seattle, WA Other HRR 3.08 3.42 10.9

Spokane, WAaOther HRR 3.04 3.40 11.9

Tacoma, WA Other HRR 3.04 3.43 12.6

Yakima, WA Other HRR 2.87 3.23 12.5

Charleston, WVaOther HRR 3.38 3.76 11.3

Huntington, WVaPotentially overserved HRR 3.36 3.87 15.2

Morgantown, WVaOther HRR 3.41 3.81 11.5

Appleton, WI Other HRR 2.88 3.29 14.5

Green Bay, WIaOther HRR 3.02 3.52 16.6

La Crosse, WIa Other HRR 2.89 3.19 10.6

Madison, WIaOther HRR 2.94 3.34 13.6

Marshfield, WI Other HRR 3.15 3.52 11.8

Milwaukee, WIaPotentially overserved HRR 3.28 3.87 18.0

Neenah, WI Other HRR 2.97 3.37 13.7

Wausau, WIa Other HRR 3.06 3.65 19.4

Casper, WY Other HRR 3.07 3.47 13.1

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

Notes: Potentially overserved HRRs are areas that were in the top half of HRRs in both utilization of 

physician services in 2000 and growth in utilization of physician services from 2000 to 2008. The rest 

of the areas were designated as other HRRs. Some HRRs cross state lines. 

a

HRR that crosses state lines. 

Page 78 GAO-09-559 Medicare Physician Services
Appendix VIII: Selected Physician Services in Appendix VIII: Selected Physician Services in Potentially Overserved and Other HRRs 

Potentially Overserved and Other HRRs 

Using BETOS code to which each procedure code in our claims data was 

assigned, we reviewed specific categories of physician services.1

 We 

collapsed data on other services and procedures into summary categories. 

We classified HRRs by utilization status.2

 Our measure of utilization—

services per beneficiary served—is based on Medicare claims data for 

services performed in the first 28 days of April 2000 and April 2008. An 

HRR was designated as potentially overserved if it was in both the top half 

of all areas in number of services per beneficiary served in 2000 and in the 

top half of the growth rate in services per beneficiary served from 2000 to 

2008. Table 17 shows the specific service categories we reviewed, the 

change in the number of services provided per 1,000 FFS beneficiaries 

from April 2000 to April 2008, and the number of and difference in services 

provided in potentially overserved and other HRRs. 

 

1

According to 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. 

2

HRRs are the 306 distinct geographic regions designated by Dartmouth researchers to 

represent regional health care markets for tertiary medical care. Each HRR contains at 

least one hospital that performs major cardiovascular procedures and neurosurgery. 

Page 79 GAO-09-559 Medicare Physician Services 
Appendix VIII: Selected Physician Services in 

Potentially Overserved and Other HRRs 

Table 17: Selected Physician Services Provided per 1,000 Medicare FFS Beneficiaries in Potentially Overserved and Other 

Hospital Referral Regions 

Service category 

Percentage 

change from 2000 

to 2008 in services 

per 1,000 Medicare 

FFS beneficiaries

Services per 1,000 

Medicare FFS 

beneficiaries in 

potentially overserved 

HRRs, 2008

Services per 1,000 

Medicare FFS 

beneficiaries in 

other HRRs, 2008 

Percentage difference 

in services per 1,000 

Medicare FFS 

beneficiaries in 

potentially overserved 

and other HRRs, 2008

All evaluation and management 15.2 1,243.0 944.7 31.6

Office visits-new patients 6.4 35.0 28.4 23.0

Office visits-established patients 14.2 572.4 472.8 21.1

Hospital visits 28.8 301.5 210.9 42.9

Emergency room visits 14.1 40.3 38.8 3.8

All imaging 41.5 461.5 385.5 19.7

CT scans 94.3 58.4 49.4 18.0

MRIs 116.5 17.0 14.8 14.8

Endoscopy 20.9 26.4 22.2 18.8

Lab tests 548.6 45.6 34.4 32.4

Other tests 26.7 170.1 120.0 41.8

All major procedures -9.4 24.3 22.5 8.0

Major cardiac procedures -22.9 12.3 10.5 16.9

Major orthopedic procedures 25.8 3.9 4.1 -6.0

Minor procedures 37.4 211.4 130.2 62.4

Ambulatory procedures 73.8 68.5 51.2 33.7

Eye procedures 28.5 13.4 12.0 11.4

Anesthesia 16.8 22.4 16.6 35.0

Oncology 10.3 33.9 26.7 27.2

All services 25.8 2,340.8 1,782.4 31.3

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

Notes: Potentially overserved HRRs are areas that were in the top half of HRRs in both utilization of 

physician services in 2000 and growth in utilization of physician services from 2000 to 2008. The rest 

of the HRRs were designated as other HRRs. Some HRRs cross state lines. 

Page 80 GAO-09-559 Medicare Physician Services
Appendix IX: Comments from the Centers for Appendix IX: Comments from the Centers for Medicare & Medicaid Services 

Medicare & Medicaid Services 

Page 81 GAO-09-559 Medicare Physician Services 
Appendix IX: Comments from the Centers for 

Medicare & Medicaid Services 

Page 82 GAO-09-559 Medicare Physician Services
Appendix IX: Comments from the Centers for 

Medicare & Medicaid Services 

Page 83 GAO-09-559 Medicare Physician Services
Appendix X: 

A

GAO Contact and Staff 

cknowledgments 

Page 84 GAO-09-559 

Appendix X: GAO Contact and Staff 

Acknowledgments 

GAO Contact A. Bruce Steinwald, (202) 512-7114 or steinwalda@gao.gov 

In addition to the contact named above, Jessica Farb, Assistant Director; 

Todd Anderson; Krister Friday; Jenny Grover; Jessica T. Lee; Richard 

Lipinski; and Sarabeth Zemel made major contributions to this report. 

 Medicare Physician Services 

Acknowledgments 

(290668) 
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