Market variations in intensity of Medicare service use and beneficiary experiences with care.

In the current debate about how to control health care costs and improve quality of care, policy makers have been discussing the implications of the considerable geographic variations in health care spending and use (Pear 2009). Patterns of health care use vary substantially across areas of the United States (Wennberg and Gittelsohn 1973) even after controlling for differences in prices and population characteristics (see review in CBO 2008). Areas with higher spending per person have more intensive practice patterns and significantly greater use of “discretionary” services such as office visits, specialist consultations, and tests compared with lower-spending areas (Fisher et al. 2003a,b;). However, additional spending and use are not related to better technical care, clinical outcomes ( Jencks et al. 2000; Fisher et al. 2003a,b; Jencks, Huff, and Cuerdon 2003; Baicker and Chandra 2004;), or physicians' self-perceived ability to provide high-quality care (Sirovich et al. 2006) across large areas. These findings are consistent for multiple clinical measures, including receipt of evidence-based services such as immunizations and outcomes such as mortality after acute myocardial infarction (Jencks et al. 2000; Fisher et al. 2003a,b; Jencks, Huff, and Cuerdon 2003; Baicker and Chandra 2004;). However, there is little information about the relationship between treatment intensity and patient experiences with care. Knowing how spending and use are associated with patient experiences, such as the ease of obtaining needed care and being treated with respect by providers, is important to developing and evaluating health care policies (IOM 2001). Some studies suggest that patient satisfaction is worse in high-use areas, but these relied upon limited measures of patient experiences with care and were restricted to a small sample of enrollees in fee-for-service (FFS) Medicare (Fisher et al. 2003a,b; Fowler et al. 2008;). Nonetheless, it is plausible that the association could go in either direction. In public opinion surveys, Americans place great value on having access to all the care that their providers think they need and fear changes that might restrict access (Blendon et al. 1998). Greater service use may also generate higher ratings of care (Davies and Ware 1988). Such preferences might cause beneficiaries in higher-intensity markets to give better overall ratings of care and their providers, especially in FFS where there are the fewest constraints on utilization of services. Furthermore, delivery of more services could enhance clinicians' knowledge of, and responsiveness to, patient needs and expectations and increase the likelihood of receiving recommended preventative care like vaccinations. High-intensity markets also have more physicians per person overall (Fisher et al. 2003a), potentially enabling easier access to care, shorter waiting times, and longer, less-hurried visits that facilitate better interactions with doctors and office staff. Alternatively, high-intensity treatment may reflect an inefficient, poorly coordinated local delivery system. Higher-intensity markets have more specialists and fewer primary care providers per person than lower-intensity markets (Fisher et al. 2003a), which may impede access to primary care and foster overreliance on specialists. To accommodate demand, visits may be shortened and interactions with physicians and staff may suffer. An overburdened, uncoordinated system may also increase the likelihood of receiving unnecessary or harmful care. Thus, patients in high-use markets might report less favorable experiences accessing care, interacting with physicians and office staff, and obtaining basic preventative services. Although Medicare Advantage (MA, Medicare's managed care program) plans could improve patient experiences by coordinating care and providing additional services made possible by higher Medicare reimbursement rates (Gold 2005), we expected that, overall, MA beneficiaries would report worse experiences than FFS beneficiaries in high-intensity areas because managed care restrictions on care would be felt most keenly there. The exception is receipt of flu and pneumonia vaccines, which MA plans have delivered more effectively overall than FFS (Landon et al. 2004). The majority of Medicare beneficiaries are enrolled in the FFS program, but the growth of MA from 12 percent in 2003 to 22 percent of all Medicare beneficiaries in 2009 (KFF 2009) makes it increasingly important to understand how beneficiaries' experiences in both programs vary with intensity of service use. In this study, we examined whether more intensive use of services is associated with an array of Medicare beneficiary experiences with care, including the ease of accessing care, the quality of interactions with doctors and staff, and overall ratings of care and their providers, in both traditional FFS Medicare and MA.