Medicare Physician Services: Utilization Trends Indicate Sustained Beneficiary Access with High and Growing Levels of Service in Some Areas of the Nation
Published: 2009-08-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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. 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.

section_title: Letter
paragraphs: 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.  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.  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  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. 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. 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. 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  on, physician services. 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.  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. Specifically, we examined beneficiary responses to two  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. 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 rural areas  nationwide and in individual states. 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.)
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. 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 Bureau 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.  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   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).
To address the third objective, we reviewed literature to identify and  construct area-level characteristics that could drive the use of physician  services. 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. We also analyzed and compared utilization of  specific types of physician services in potentially overserved and other  areas (see app. IV for more information).
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.
subsections: section_title: Background
paragraphs: 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   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. 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. 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 Medicare- covered 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  her charge and the Medicare-approved amount—a practice known as  balance billing.
subsections: section_title: Access to Physician Services
paragraphs: 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, 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.  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.
section_title: Geographic Variation in the Utilization of Physician Services
paragraphs: 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.
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. 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. Dartmouth researchers concluded that geographic variation in  Medicare spending can be attributed to how physicians respond to  technology, capital, and other resources under FFS. 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. 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.
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. 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. 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.
section_title: Indicators Show Few Problems in Beneficiary Access to Physician Services
paragraphs: 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.
subsections: section_title: Few Beneficiaries Reported Major Access Problems in 2007 and 2008
paragraphs: 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.
section_title: Proportion of Beneficiaries Receiving Physician Services Increased from 2000 to 2008
paragraphs: 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. 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.
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.
section_title: Average Number of Physician Services Provided per Beneficiary Rose from 2000 to 2008
paragraphs: 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).
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.
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  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. 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.
section_title: Indicators of Physician Willingness to Serve Medicare Beneficiaries Remain Favorable
paragraphs: 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. 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  about 31.9 million in 2007, as more beneficiaries joined Medicare  Advantage plans. Increases in the number of physicians billing Medicar the number of physicians billing Medicar in spite of the decline in Medicare FFS beneficiaries, suggest that in the  in spite of the decline in Medicare FFS beneficiaries, suggest that in the  aggregate, ph aggregate, physicians continued to accept FFS Medicare patients during  this period. ysicians continued to accept FFS Medicare patients during  this period.
From April 2000 to April 2008, the majority of Medicare physician services were performed by physicians who accepted Medicare’s fees as payment  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 t in  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 n in  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 icipating physicians—that is, physicians who formally agreed to participate in the  physicians—that is, physicians who formally agreed to participate in the  on assignment—increased from   Medicare program and submit all claims   Medicare program and submit all claims  on assignment—increased from  about 95 percent in April 2 about 95 percent in April 2000 to about   97 percent in April 2008. 000 to about   97 percent in April 2008.
Physicians may decide on an annual basis whether they will be Medicare participating  physicians.
section_title: Potentially Overserved Areas Tend to Be in More Densely Populated Urban Regions and the Eastern Part of the Country
paragraphs: 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.
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.
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.
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  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-Naperville- Joliet, and Philadelphia, were potentially overserved areas. In contrast,  the largest western metropolitan divisions of Los Angeles-Long Beach- Glendale, Dallas-Plano-Irving, and Santa Ana-Anaheim-Irvine were not  potentially overserved areas by our measure. 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.)
section_title: Potentially Overserved Areas Are Largely Similar to Other Areas, with the Exception of Physician Practice Patterns
paragraphs: 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.
subsections: section_title: Demographic Characteristics and Capacity to Provide Health Care Are Similar among Potentially Overserved and Other Areas
paragraphs: 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. Potentially overserved areas and other areas also had a similar  racial composition and average income levels, although they differed  somewhat in educational attainment. 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.
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  beds and hospital utilization and between physician supply and the rate of  physician visits.
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.  Conversely, studies have demonstrated that areas with more specialty  services are associated with higher spending but not better access or  health outcomes.
section_title: Beneficiary Satisfaction Is Similar in Potentially Overserved and Other Areas
paragraphs: 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.
section_title: Potentially Overserved and Other Areas Have Substantial Differences in Use of Certain Types of Physician Services
paragraphs: 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  trends in selected physician services in potentially overserved and other  areas.)
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  various reasons, including physician discretion. 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. 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.
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.
section_title: Concluding Observations
paragraphs: 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.
section_title: Agency and Industry Comments and Our Evaluation
subsections: section_title: Agency Comments
paragraphs: 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.
section_title: American Medical Association Comments
paragraphs: 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  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.
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section_title: Appendix I: Scope and Methodology
paragraphs: 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-for- service (FFS) program. 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. 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.
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.
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  more than 60 million claims per year. 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). 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. 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  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.
To indicate physicians’ willingness to participate in Medicare, we  determined the number of physicians billing Medicare from 2000 through  2007, whether services were performed by participating or  nonparticipating physicians, and whether claims for physician services  were paid on assignment or not on assignment. We did not adjust the data  for factors that could affect the provision and use of physician services,  such as incidence of illness or coverage of new benefits.
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  the U.S. Census Bureau 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.
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.
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. 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. We obtained  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. We collapsed data on other services and procedures  into summary categories.
subsections: section_title: Data Reliability and Limitations
paragraphs: 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. 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  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.
section_title: Appendix II: Average Utilization Values by Geographic Area Type
paragraphs: 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.
section_title: Appendix III: Utilization Status of Geographic Areas
paragraphs: 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.)
section_title: Appendix IV: Selected Physician Services in Potentially Overserved and Other Areas
paragraphs: Using the BETOS code to which each procedure code in our claims data  was assigned, we reviewed specific categories of physician services. 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.
section_title: Appendix V: Utilization Status of Medicare Physician Payment Localities
paragraphs: 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.  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.)
section_title: Appendix VI: Selected Physician Services in Potentially Overserved and Other Medicare Physician Payment Localities
paragraphs: Using the BETOS code to which each procedure code in our claims data  was assigned, we reviewed specific categories of physician services. 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. 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.
section_title: Appendix VII: Utilization Status of Hospital Referral Regions
paragraphs: 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.)
section_title: Appendix VIII: Selected Physician Services in Potentially Overserved and Other HRRs
paragraphs: Using BETOS code to which each procedure code in our claims data was  assigned, we reviewed specific categories of physician services. We  collapsed data on other services and procedures into summary categories.  We classified HRRs 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. 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.
section_title: Appendix IX: Comments from the Centers for Medicare & Medicaid Services
section_title: Appendix X: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: 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.