Medicare Physician Services
Use of Services Increasing Nationwide and Relatively Few Beneficiaries Report Major Access Problems Gao ID: GAO-06-704 July 21, 2006Congress, policy analysts, and groups representing physicians have periodically raised concerns that Medicare's efforts to control spending on physician services by limiting annual updates to physician fees could have an adverse impact on beneficiaries' access to physician services. These concerns were heightened in 2002 when Medicare's formula for setting physician fees required a 5.4 percent reduction in fees to help moderate rapid spending increases. From 2003 to 2006, fees have not grown as rapidly as the estimated cost to physicians of providing services, and concerns about access have remained. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 requires GAO to study access to physician services by beneficiaries in the traditional fee-for-service (FFS) program. This report focuses on (1) trends and patterns in beneficiaries' perceptions of the availability of physician services from 2000 through 2004, (2) trends in beneficiaries' utilization of physician services from 2000 through 2005, and (3) indicators of physician supply and willingness to serve Medicare beneficiaries from 2000 through 2005. GAO analyzed the most recent data available, including several years of data from an annual survey of FFS Medicare beneficiaries as well as utilization trends based on all Medicare physician claims for services provided in April of each year from 2000 through 2005.
From 2000 through 2004, among beneficiaries who needed access to physician services, the percentages reporting major difficulties--that is, "having a big problem" finding a personal provider or specialist or never being able to schedule an appointment promptly--remained relatively constant. Nationwide, no more than about 7 percent of beneficiaries reported a major access difficulty. We identified certain beneficiary characteristics--including health status, age, and race--that were associated with beneficiaries' reporting major access difficulties. In general, from April 2000 to April 2005, an increasing proportion of beneficiaries received physician services and an increasing number of physician services were provided to beneficiaries who were treated. This trend was evident in every state's urban areas and nearly every state's rural areas. Two other access related indicators--the number of physicians billing Medicare for services and the proportion of services for which Medicare's fees were accepted as payment in full--increased from April 2000 to April 2005. These increases suggest that there was no reduction in the predominant tendency of physicians to accept Medicare patients and payments. The increases in utilization and complexity of services GAO observed demonstrate that beneficiaries were able to access physician services. However, GAO did not determine the medical appropriateness of these increases. Although access to appropriate care is important, the implications of these trends in utilization for the long-term fiscal sustainability of the Medicare program would require careful examination. CMS agreed with GAO's findings and conclusions, stating that the analysis was well-conceived and executed. CMS also provided technical comments, which GAO incorporated as appropriate.
GAO-06-704, Medicare Physician Services: Use of Services Increasing Nationwide and Relatively Few Beneficiaries Report Major Access Problems
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
July 2006:
Medicare Physician Services:
Use of Services Increasing Nationwide and Relatively Few Beneficiaries
Report Major Access Problems:
Medicare Beneficiary Access:
GAO-06-704:
GAO Highlights:
Highlights of GAO-06-704, a report to congressional committees
Why GAO Did This Study:
Congress, policy analysts, and groups representing physicians have
periodically raised concerns that Medicare‘s efforts to control
spending on physician services by limiting annual updates to physician
fees could have an adverse impact on beneficiaries‘ access to physician
services. These concerns were heightened in 2002 when Medicare‘s
formula for setting physician fees required a 5.4 percent reduction in
fees to help moderate rapid spending increases. From 2003 to 2006, fees
have not grown as rapidly as the estimated cost to physicians of
providing services, and concerns about access have remained.
The Medicare Prescription Drug, Improvement, and Modernization Act of
2003 requires GAO to study access to physician services by
beneficiaries in the traditional fee-for-service (FFS) program. This
report focuses on (1) trends and patterns in beneficiaries‘ perceptions
of the availability of physician services from 2000 through 2004, (2)
trends in beneficiaries‘ utilization of physician services from 2000
through 2005, and (3) indicators of physician supply and willingness to
serve Medicare beneficiaries from 2000 through 2005. GAO analyzed the
most recent data available, including several years of data from an
annual survey of FFS Medicare beneficiaries as well as utilization
trends based on all Medicare physician claims for services provided in
April of each year from 2000 through 2005.
What GAO Found:
From 2000 through 2004, among beneficiaries who needed access to
physician services, the percentages reporting major difficulties”that
is, ’having a big problem“ finding a personal provider or specialist or
never being able to schedule an appointment promptly”remained
relatively constant. Nationwide, no more than about 7 percent of
beneficiaries reported a major access difficulty. We identified certain
beneficiary characteristics”including health status, age, and race”that
were associated with beneficiaries‘ reporting major access
difficulties.
In general, from April 2000 to April 2005, an increasing proportion of
beneficiaries received physician services and an increasing number of
physician services were provided to beneficiaries who were treated (see
figure). This trend was evident in every state‘s urban areas and nearly
every state‘s rural areas.
Two other access related indicators”the number of physicians billing
Medicare for services and the proportion of services for which
Medicare‘s fees were accepted as payment in full”increased from April
2000 to April 2005. These increases suggest that there was no reduction
in the predominant tendency of physicians to accept Medicare patients
and payments.
The increases in utilization and complexity of services GAO observed
demonstrate that beneficiaries were able to access physician services.
However, GAO did not determine the medical appropriateness of these
increases. Although access to appropriate care is important, the
implications of these trends in utilization for the long-term fiscal
sustainability of the Medicare program would require careful
examination.
CMS agreed with GAO‘s findings and conclusions, stating that the
analysis was well-conceived and executed. CMS also provided technical
comments, which GAO incorporated as appropriate.
Figure: Trends in Access to Physician Services, April 2000 through
April 2005:
[See PDF for Image]
Source: GAO analysis of Medicare Part B claims and enrollment data from
the Centers for Medicare and Medicaid Services.
[End of Figure]
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-704].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact A. Bruce Steinwald at
(202) 512-7101 or steinwalda@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
Overall Trends in Beneficiary Perceptions of Major Access Difficulties
Were Stable over Time, with Some Beneficiaries More Likely Than Others
to Report Difficulties:
From 2000 to 2005, Both Proportion of Beneficiaries Receiving Physician
Services and Number of Services Provided per Beneficiary Increased:
From 2000 to 2005, Indicators of Physician Supply and Willingness to
Serve Medicare Beneficiaries Were Favorable:
Concluding Observations:
Agency and Industry Comments and Our Evaluation:
Appendix I: Methods and Models Used in Analyzing Factors Affecting
Medicare Beneficiaries' Perceptions of Access:
Appendix II: Methods Used to Analyze Medicare Claims Data:
Appendix III: Specific Physician Services Reviewed:
Appendix IV: Comments from the Centers for Medicare & Medicaid
Services:
Appendix V: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Example of Medicare Payment and Beneficiary Coinsurance for
Physician Services When the Medicare-Approved Amount Is $100:
Table 2: Medicare Beneficiary Responses to Three CAHPS Survey Questions
regarding Access to Physician Services, 2000-2004:
Table 3: Average Percentage of Medicare Beneficiaries Who Reported
Major Difficulties Accessing Physician Services by Self-Reported Health
Status, 2000-2004:
Table 4: Average Percentage of Medicare Beneficiaries Who Reported
Having Major Difficulties Accessing Physician Services by Beneficiary
Age Group, 2000-2004:
Table 5: Average Percentage of Medicare Beneficiaries Who Reported
Having Major Difficulties Accessing Physician Services by Race, 2000-
2004:
Table 6: Average Percentage of Medicare Beneficiaries Who Reported
Having Major Difficulties Accessing Physician Services by Supplemental
Health Insurance Coverage, 2000-2004:
Table 7: Changes in Volume and Complexity of Physician Services
Provided per Medicare Beneficiary, April 2000-April 2005:
Table 8: CAHPS Survey Questions Related to Physician Access, 2000-2004:
Table 9: Estimated Effects of Selected Medicare Beneficiary and Area
Characteristics on Reporting Major Difficulty Accessing Physician
Services, 2000-2004:
Table 10: Percentage Change in the Number of Services Provided per
1,000 Medicare Beneficiaries, April 2000 to April 2005:
Figures:
Figure 1: Variation by State in Percentage of Medicare Beneficiaries
Who Reported Having a Big Problem Finding a Personal Doctor or Nurse,
2004:
Figure 2: Percentage Point Change in Medicare Beneficiary Reports of
Having a Big Problem Finding a Personal Doctor or Nurse, 2000 to 2004:
Figure 3: Percentage of Medicare Beneficiaries Receiving Physician
Services in April, 2000-2005:
Figure 4: Variation by State Urban and Rural Areas in Proportion of
Medicare Beneficiaries Receiving Physician Services, April 2005:
Figure 5: Percentage Point Change from 2000 to 2005 in Proportion of
Medicare Beneficiaries Receiving Physician Services in April, by State
Urban and Rural Areas:
Figure 6: Number of Physician Services Provided per 1,000 Medicare
Beneficiaries Served in April, 2000-2005:
Figure 7: Variation by State Urban and Rural Areas in the Average
Number of Physician Services Provided per 1,000 Medicare Beneficiaries
Served, April 2005:
Figure 8: Change from 2000 to 2005 in Number of Physician Services
Provided per 1,000 Medicare Beneficiaries in April, by State Urban and
Rural Areas:
Figure 9: Number of Physician Services Provided per 1,000 Medicare
Beneficiaries in April, 2000 and 2004:
Figure 10: Number of Services Provided per 1,000 Medicare Beneficiaries
in April, by Service Category, 2000 and 2005:
Figure 11: Number of Office Visits per 1,000 Medicare Beneficiaries in
April by New and Established Patients, 2000-2005:
Figure 12: Number of Physicians Billing Medicare for Services Provided
to Medicare Beneficiaries in April, 2000-2005:
Figure 13: Proportion of Physician Services by Medicare Participation
and Assignment Status, April 2000 and April 2005:
Abbreviations:
AMA: American Medical Association:
ARF: Area Resource File:
BETOS: Berenson- Eggers Type of Service:
CABG: coronary artery bypass graft:
CAHPS: Consumer Assessment of Health Plans Study:
CAT: computed axial tomography:
CMS: Centers for Medicare & Medicaid Services:
E&M: evaluation and management:
FFS: fee-for-service:
FQHC: federally qualified health center:
GDP: gross domestic product:
HSC: Center for Studying Health System Change:
MedPAC: Medicare Payment Advisory Commission:
MEI: Medicare Economic Index:
MSA: metropolitan statistical area:
MVPS: Medicare volume performance standard:
NCH: National Claims History file:
RHC: rural health clinic:
RVU: relative value units:
SGR: sustainable growth rate:
United States Government Accountability Office:
Washington, DC 20548:
July 21, 2006:
Congressional Committees:
Since the early 1990s, Congress, policy analysts, and groups
representing physicians have periodically raised concerns that
Medicare's efforts to control spending on physician services by
limiting annual updates to physician fees could have an adverse impact
on beneficiaries' access to physician services. These concerns were
heightened in 2002, when Medicare's formula for setting physician fees
required a 5.4 percent reduction in fees to help moderate rapid
spending increases for physician services.[Footnote 1] In 2003 through
2006, a combination of administrative and legislative changes averted
additional fee declines that would otherwise have occurred under the
formula. However, concerns about access remained because fees in these
years did not grow as rapidly as the increase in the estimated cost to
physicians for providing their services.[Footnote 2] In the absence of
additional actions, Medicare's formula is projected to reduce physician
fees by approximately 5 percent each year for 9 years beginning in
2007.[Footnote 3]
In January 2005, we reported that based on beneficiaries' utilization
of physician services, the 2002 fee cut did not appear to have an
immediate impact on beneficiary access to physician services and that
beneficiary access increased from April 2000 to April 2002.[Footnote 4]
Our report did not assess, however, how beneficiary access to physician
services might have changed since 2002 or how beneficiaries perceived
their access to physician services.
The Medicare Prescription Drug, Improvement, and Modernization Act of
2003 directed us to study access to physician services by beneficiaries
in the traditional fee-for-service (FFS) program.[Footnote 5]
Specifically, we examined:
* trends and patterns in beneficiaries' perceptions of the availability
of physician services from 2000 through 2004,
* trends in beneficiaries' utilization of physician services from 2000
through 2005, and:
* indicators of physician supply and willingness to serve Medicare
beneficiaries from 2000 through 2005.
In addressing these objectives, we analyzed the most recent data
available from two data sources. First, we analyzed several years of
data from an annual Centers for Medicare & Medicaid Services (CMS)
patient satisfaction survey of FFS Medicare beneficiaries, called the
Consumer Assessment of Health Plans Study (CAHPS®).[Footnote 6]
Specifically, we examined beneficiaries' responses for the years 2000
through 2004 to three questions related to access to physician
services.[Footnote 7] The survey questions asked whether:
* finding a personal provider was "no problem," "a small problem," or
"a big problem";
* seeing a specialist was "no problem," "a small problem," or "a big
problem"; and:
* beneficiaries were able to schedule an appointment for routine care
promptly "always," "usually," "sometimes," or "never."
We measured access problems based only on beneficiaries' responses in
the most negative category--that is, "a big problem" or "never." This
approach enabled us to be as definitive as possible in describing
beneficiaries' perceptions of access difficulties.[Footnote
8],[Footnote 9],[Footnote 10] Because the personal provider and prompt
appointment questions were not limited to physician services, the
proportion of beneficiaries who reported major difficulties for these
questions may not be specific to difficulties accessing physicians. We
also sought to determine whether certain characteristics, such as age,
race, health status, and supply of physicians in a beneficiary's county
of residence--15 beneficiary and area characteristics in all--were
associated with the survey responses. To determine these relationships,
we conducted a multivariate statistical analysis that yields an
estimate of each characteristic's effect, controlling for the effects
of all other characteristics in the analysis. (See app. I for more
details on the methodology of our analysis of the CAHPS data.)
Second, we analyzed utilization trends for 6 years by examining all
Medicare physician claims for services provided in April of each year
from 2000 through 2005.[Footnote 11],[Footnote 12],[Footnote 13] These
data encompass several periods: 2 years in which fee increases were
greater than the increase in the estimated cost of providing services
(2000 and 2001), 1 year in which fees decreased (2002), and 3 years in
which fee increases were less than the increase in the estimated cost
of providing services (2003, 2004, and 2005). Because it was outside
the scope of our study, we did not adjust the claims data for factors
that could affect the provision and use of physician services, such as
incidence of illness or coverage of new benefits. Thus, we could not
determine whether the amount of physician services provided over our
period of study was appropriate. We also used the claims data to
analyze trends in the number of physicians billing Medicare and in the
proportion of services for which Medicare was accepted as payment in
full. (See app. II for more details on our analysis of the Medicare
claims data.)
We ensured the reliability of the CAHPS and claims data used in this
report by performing appropriate electronic data checks and by
interviewing agency officials who were knowledgeable about the data.
Specifically, we examined the accuracy and completeness of the CAHPS
data by testing for implausible values and internal consistency and by
interviewing experts at CMS about whether the CAHPS data could
appropriately be used as we intended. The Medicare claims data we used
are considered to be generally reliable, as they are used by the
Medicare program as a record of payments to health care providers and
are closely monitored by both CMS and the Medicare carriers--
contractors that process, review, and pay claims for Part B-covered
services. In addition, we examined the claims data files for obvious
errors, missing values, values outside of expected ranges, and dates
outside of expected time frames. We also interviewed experts at CMS who
regularly use the claims data for evaluation and analysis. We found
that both the CAHPS and claims data were sufficiently reliable for the
purpose of our analyses. We conducted our work from October 2004
through June 2006 in accordance with generally accepted government
auditing standards.
Results in Brief:
From 2000 through 2004, among beneficiaries who needed access to
physician services, the percentages reporting major difficulties--that
is, "having a big problem" finding a personal provider or specialist or
never being able to schedule an appointment promptly--remained
relatively constant. Nationwide, relatively few beneficiaries--no more
than about 7 percent--reported a major access difficulty. Beneficiaries
living in urban areas and beneficiaries living in rural areas reported
major access difficulties in similar percentages. Although the
proportion of beneficiaries who reported major difficulties varied
considerably among states--by as much as 12 percentage points--their
perceptions over time of access to physician services in the vast
majority of states remained nearly the same or improved. In our
analysis of beneficiary subgroups, we identified certain beneficiary
characteristics--including health status, age, and race--that were
associated with beneficiaries' reporting a big problem finding a
personal provider or specialist or never being able to schedule an
appointment promptly. Specifically, survey respondents who rated their
health as poor, were under 65 and disabled, were not white, and had no
supplemental health insurance or had supplemental insurance from
Medicaid, were more likely to have experienced physician access
difficulties.
Two indicators of beneficiary access to physician services--the
proportion of beneficiaries who received services and the number of
services provided to beneficiaries who were treated--suggest an
increase in access from April 2000 to April 2005. In particular, the
proportion of beneficiaries receiving services rose by 4 percentage
points nationwide--from about 41 percent to about 45 percent; by 4
percentage points in urban areas--from about 42 percent to 46 percent;
and by 3 percentage points in rural areas--from about 39 percent to
about 42 percent. Moreover, the average number of services provided per
1,000 beneficiaries nationwide rose by 14 percent, in urban areas by 15
percent, and in rural areas by 12 percent. Likewise, within every
state's urban areas and almost every state's rural areas, the
proportion of beneficiaries who received services increased, and within
all states' urban and rural areas, the average number of services
provided to beneficiaries who received services increased. Volume
generally increased, for specific services--office visits, procedures,
imaging services, and tests. Finally, services per beneficiary rose not
only in number but also in complexity for the April 2000-April 2005
period we examined.
Two other access related indicators--the number of physicians billing
Medicare for services and the proportion of services for which
Medicare's fees were accepted as payment in full--increased from April
2000 to April 2005. Specifically, the number of physicians billing
Medicare increased by 11 percent, while the number of Medicare
beneficiaries increased by 8 percent, over the period covered by our
claims analysis. In addition, from April 2000 through April 2005, the
vast majority of Medicare services were performed by participating
physicians--that is, physicians who accept Medicare's fees as payment
in full for services provided. This proportion increased over this
period from 95 percent to over 96 percent. The increase suggests that
there was no reduction in the predominant tendency of physicians to
accept Medicare patients and payments.
CMS agreed with our findings and conclusions, stating that our analysis
of existing data was well-conceived and executed. Officials from the
American Medical Association (AMA) stated that our analysis of survey,
claims, and physician participation data showed no deterioration in
beneficiaries' access to physician services over the time period
studied. However, AMA officials cautioned that the results of this
analysis should not be interpreted as an improvement in access and
suggested that the report place more emphasis on our finding that
beneficiaries with certain characteristics, such as those in poor
health, were more likely, relative to other beneficiaries, to respond
that they experienced major difficulty accessing physician services.
CMS and AMA also provided technical comments, which we incorporated as
appropriate.
Background:
Medicare is the federally financed health insurance program for persons
age 65 and over, certain individuals with disabilities, and individuals
with end-stage kidney disease. In 2005 there were approximately 43
million Medicare beneficiaries.[Footnote 14] Eligible individuals are
automatically covered by Part A, which helps pay for inpatient
hospital, skilled nursing facility, and hospice care, as well as home
health care that follows a stay in a hospital or skilled nursing
facility. Most eligible individuals elect to pay a monthly premium--
$88.50 a month in 2006--to obtain Medicare Part B coverage, which helps
pay for physician services, hospital outpatient services, and certain
other services, such as physical therapy.[Footnote 15] In addition,
most Medicare beneficiaries have supplemental insurance that helps them
pay for their care, thus reducing financial barriers to obtaining care.
In 2002, 90 percent of Medicare beneficiaries obtained supplemental
coverage either through their former employer (32 percent), a privately
purchased supplemental insurance policy known as Medigap (26 percent),
Medicaid (16 percent), or some other program.
Medicare beneficiaries may choose how they receive covered services. In
2005, most beneficiaries in Part B--about 87 percent--were enrolled in
Medicare's traditional FFS option and could obtain care from any
licensed provider willing to accept Medicare patients. The remaining
beneficiaries were enrolled in private health plans that contract to
serve Medicare beneficiaries and could obtain care through their health
plans. These plans typically contract with some of the same physicians
and hospitals that participate in FFS Medicare.
Over the last several years, rapid spending growth for Part B services-
-driven in part by spending growth for physician services--has
heightened concerns about the Medicare program's long-range fiscal
outlook. Medicare spending for physician services has increased from
about $32 billion in 1998 to about $59 billion in 2005. We and others
have noted that because of demographic trends and increases in per
beneficiary health care spending, the Medicare program in its present
form is not sustainable. Long-term projections indicate that Medicare's
burden on the federal budget and the economy will balloon--almost
tripling by 2035 and quadrupling by 2075.[Footnote 16] Moderating
spending growth for physician services, in part by seeking to ensure
that services provided are necessary and appropriate, will continue to
be part of the larger effort to ensure future program sustainability.
Some Medicare Spending for Physician Services May Be Unnecessary:
The provision of more services does not necessarily mean better health
care or better health care outcomes. The wide geographic variation in
Medicare spending for physician services--unrelated to beneficiary
health status or outcomes--provides evidence that health needs alone do
not determine spending. Furthermore, some studies have shown that in
some instances growth in the number of services provided may lead to
medical harm.[Footnote 17] Payments under the Medicare program,
however, generally do not foster quality, efficiency, or medical
efficacy. Therefore, some of the growth in beneficiary utilization of,
and spending for, physician services may not be warranted. Although
access to appropriate care is important, overutilization of services
represents wasteful spending and may, in some instances, harm
beneficiaries. Consequently, policymakers have deemed it both
reasonable and desirable to question the appropriateness of current and
projected spending on physician services, and to explicitly consider
the affordability of such spending when setting physician fees.
Efforts to Control Medicare Spending on Physician Services Include Fee
Schedule and Spending Targets:
In the 1990s, several reforms to Medicare physician fees were
implemented to help control rapid spending growth for physician
services in the traditional FFS Medicare program. Among those reforms
were the establishment of a national fee schedule and a system of
spending targets.[Footnote 18] The target system was designed to
control Medicare physician spending growth attributable to increases in
the number of services, known as volume, and in the complexity and
costliness of services, known as intensity. Under the design of the fee
schedule and target system, annual updates to physician fees depend, in
part, on whether actual spending has fallen below or exceeded the
target. Fees are permitted to increase at least as fast as the costs of
providing physician services as long as volume and intensity growth
remains below a specified rate--currently, a little more than 2 percent
a year. If spending associated with volume and intensity grows faster
than the specified rate, the target system reduces fee increases or
causes fees to fall.
Medicare's Physician Fee Schedule Based on Relative Values:
Under the fee schedule, Medicare pays for more than 7,000 services that
can be classified in several broad categories--patient evaluation and
management, which includes office visits, hospital visits, and
consultations; procedures, which includes inpatient and minor
surgeries; imaging, which includes X rays and more sophisticated
diagnostic radiology, such as computed axial tomography (CAT) scans;
and tests, which includes urinalysis and blood chemistries. Within
these broad categories are varying levels of service complexity.
The fee schedule expresses this complexity through relative value units
(RVU), which account for the amount of physician time, expertise, and
resources required to deliver a service compared to other
services.[Footnote 19],[Footnote 20] The relative complexity--as
measured by the costliness--of each service is compared to a benchmark
service, defined as a midlevel office visit. For example, if a midlevel
office visit had an RVU value of 1.000,[Footnote 21] a service with
1.475 RVUs is estimated to be 47.5 percent more costly to provide than
the midlevel office visit; while a service with 0.925 RVUs is estimated
to be 7.5 percent less costly than the midlevel office visit. In this
way, RVU weights quantify the complexity of services provided.
Medicare's Payments to Physicians for Services Are Affected by
Physician Participation and Assignment Status of Claim:
Traditional FFS Medicare generally pays physicians a predetermined
amount for each service provided. Physicians who "accept assignment"
agree to accept Medicare's fee as payment in full for the services they
provide to Medicare beneficiaries. This includes the coinsurance amount
(usually 20 percent) paid by the beneficiary to the physician.[Footnote
22] Physicians who sign Medicare participation agreements--referred to
as participating physicians--must accept assignment for all the covered
services they provide to beneficiaries. Physicians who do not sign
participation agreements--referred to as nonparticipating physicians--
can either opt to accept assignment on a service-by-service basis or
not at all. When a nonparticipating physician accepts assignment the
fee schedule amount, also known as the Medicare-approved amount, is
reduced by 5 percent. Medicare pays the physician 80 percent of the
reduced amount; the beneficiary pays 20 percent of the reduced amount.
When a nonparticipating physician does not accept assignment, the
Medicare-approved amount is also reduced by 5 percent, but the
physician is allowed to collect an additional amount from the
beneficiary that more than offsets the 5 percent fee reduction--a
practice known as balance billing.[Footnote 23] Specifically,
nonparticipating physicians who do not accept assignment can charge up
to 15 percent over the reduced Medicare approved amount and thus
receive in total approximately 109 percent of the Medicare approved fee
for that service (this amount is known as the "limiting
charge").[Footnote 24] The beneficiary typically has to pay the
nonparticipating physician the full amount of the limiting charge.
Medicare later reimburses the beneficiary for 80 percent of the reduced
Medicare approved amount. (See table 1.)
Table 1: Example of Medicare Payment and Beneficiary Coinsurance for
Physician Services When the Medicare-Approved Amount Is $100:
Amount charged;
Participating physician: $150;
Physician accepting assignment but not participating: $150;
Physician not accepting assignment: $150.
Medicare-approved amount;
Participating physician: $100;
Physician accepting assignment but not participating: $95;
Physician not accepting assignment: $95.
Limiting charge (15 percent more than the Medicare-approved amount);
Participating physician: Not applicable;
Physician accepting assignment but not participating: Not applicable;
Physician not accepting assignment: $109.25.
Medicare payment (80 percent);
Participating physician: $80;
Physician accepting assignment but not participating: $76;
Physician not accepting assignment: $76.
Beneficiary coinsurance (usually 20 percent);
Participating physician: $20;
Physician accepting assignment but not participating: $19;
Physician not accepting assignment: $33.25[A].
How payment is made;
Participating physician: Medicare directly pays physician. Beneficiary
pays coinsurance;
Physician accepting assignment but not participating: Medicare directly
pays physician. Beneficiary pays coinsurance;
Physician not accepting assignment: Beneficiary pays physician limiting
charge. Medicare reimburses beneficiary for its share (80 percent of
the approved amount).
Source: GAO analysis of CMS information.
[A] The beneficiary pays the coinsurance of $19.00 plus the $14.25
difference between the Medicare payment to the physician and the
limiting charge.
[End of table]
Studies of Medicare Beneficiary Access Suggest Few Problems Nationwide:
Studies from the Medicare Payment Advisory Commission (MedPAC), CMS,
and the Center for Studying Health System Change (HSC) have reported
that Medicare beneficiary access to physician services nationwide has
been good in recent years, with some exceptions. In its March 2006
report,[Footnote 25] MedPAC reported the results of its 2005 survey
comparing patient access measures between Medicare beneficiaries and
privately insured individuals age 50 to 64. It found that similar
proportions of Medicare and privately insured individuals had no
problems finding a physician or scheduling an appointment.
Specifically, 75 percent of both Medicare beneficiaries and of
privately insured individuals had no problem finding a new primary care
physician,[Footnote 26] while 74 percent of Medicare beneficiaries and
67 percent of privately insured individuals never experienced an
unwanted delay in getting an appointment for routine care.[Footnote 27]
These results are generally consistent with previous MedPAC reports on
access related solely to Medicare beneficiaries.[Footnote 28]
In 2005, CMS reported findings from its "targeted" beneficiary survey,
that is, a survey focused only on beneficiaries in 11 markets who might
have been likely to experience problems accessing physician services
based on evidence from CMS monitoring activities and responses to the
2001 CAHPS survey.[Footnote 29],[Footnote 30] The survey results
generally showed stability or improvement in obtaining access from 2003
through 2004. For example, the proportion of FFS Medicare beneficiaries
who reported that seeing a doctor "has gotten harder in the past year
or two" remained the same--at 7 percent--for both years. In addition,
the proportions of beneficiaries reporting problems getting routine
care appointments in 2003 and 2004 declined from 27 percent to 21
percent. CMS also noted that certain groups of beneficiaries--those
transitioning to a new physician, disabled individuals, those in poor
or fair health, those with low incomes, and those without supplemental
coverage--had higher rates of problems accessing physician services.
For example, about 10 percent of disabled (under age 65) Medicare
beneficiaries reported access problems related to physicians'
willingness to accept Medicare, whereas no more than 4 percent of
beneficiaries older than 65 (and therefore eligible for Medicare on the
basis of age) reported the same problem.
A January 2006 HSC report, based on periodic surveys of physicians,
found that the proportion of physicians nationwide accepting new
Medicare patients remained unchanged for the two most recent survey
periods.[Footnote 31],[Footnote 32] Specifically, for both the 2000-
2001 and 2004-2005 survey periods, HSC found that over 70 percent of
physicians surveyed accepted all new Medicare patients.[Footnote 33]
Only a small fraction--less than 4 percent--of physicians responded
that they did not accept any new Medicare patients. HSC concluded that
despite fluctuations in Medicare payments to physicians, access has
remained high for beneficiaries and comparable to access rates for
privately insured individuals.
Overall Trends in Beneficiary Perceptions of Major Access Difficulties
Were Stable over Time, with Some Beneficiaries More Likely Than Others
to Report Difficulties:
From 2000 through 2004, the percentage of beneficiaries who reported
major difficulties accessing physician services--that is, "having a big
problem" finding a personal provider or specialist or never being able
to promptly schedule a routine appointment--did not vary much from year
to year, and relatively small percentages of beneficiaries reported
these difficulties. The percentage of beneficiaries who reported major
difficulties accessing physician services varied widely by state, but
in the vast majority of states this percentage remained relatively
constant or declined from 2000 through 2004. Beneficiaries living in
urban areas and beneficiaries living in rural areas reported major
access difficulties in similar percentages. However, beneficiaries with
certain characteristics--such as those in poor health or less than 65
years of age--were more likely to report access difficulties relative
to other beneficiaries regardless of where they lived.
Proportions of Beneficiaries Reporting Major Access Difficulties Were
Relatively Small and Stable:
The percentage of beneficiaries who reported major difficulties
accessing physician services did not vary substantially from 2000
through 2004. (See table 2.) For example, among those who needed to
find a personal doctor or nurse,[Footnote 34] about 7 percent of
beneficiaries reported a big problem in 2000, and about 5 percent
reported a big problem in 2004. Similarly, among those who needed to
see a specialist,[Footnote 35] the percentage of beneficiaries who
reported having a big problem varied by less than 2 percentage points-
-from a high of 5.6 percent in 2000 to a low of 4.3 percent in 2004.
Among beneficiaries who needed to schedule an appointment,[Footnote 36]
the percentage who reported never being able to schedule an appointment
promptly remained at less than 2 percent throughout the 5-year period.
Table 2: Medicare Beneficiary Responses to Three CAHPS Survey Questions
regarding Access to Physician Services, 2000-2004:
CAHPS survey questions regarding access to physician services: How much
of a problem was it finding a personal doctor or nurse you were happy
with since enrolling in Medicare?;
Percentage of respondents who reported having major difficulties: 2000:
7.1;
Percentage of respondents who reported having major difficulties: 2001:
5.6;
Percentage of respondents who reported having major difficulties: 2002:
6.0;
Percentage of respondents who reported having major difficulties: 2003:
5.8;
Percentage of respondents who reported having major difficulties: 2004:
5.3.
CAHPS survey questions regarding access to physician services: In the
last 6 months, how much of a problem was it seeing a specialist?;
Percentage of respondents who reported having major difficulties: 2000:
5.6;
Percentage of respondents who reported having major difficulties: 2001:
4.6;
Percentage of respondents who reported having major difficulties: 2002:
5.0;
Percentage of respondents who reported having major difficulties: 2003:
4.9;
Percentage of respondents who reported having major difficulties: 2004:
4.3.
CAHPS survey questions regarding access to physician services: In the
last 6 months, how often did you get an appointment promptly?;
Percentage of respondents who reported having major difficulties: 2000:
1.1;
Percentage of respondents who reported having major difficulties: 2001:
1.1;
Percentage of respondents who reported having major difficulties: 2002:
1.6;
Percentage of respondents who reported having major difficulties: 2003:
1.5;
Percentage of respondents who reported having major difficulties: 2004:
1.5.
Source: GAO analysis of CMS's Medicare CAHPS surveys.
Notes: We define major difficulties as reporting "a big problem"
finding a personal doctor or nurse or seeing a specialist or as
reporting "never" being able to promptly schedule a health care
appointment. These questions were paraphrased for the purposes of this
report. The total number of individuals responding to each question
varied from year to year. We reported proportions only for those
beneficiaries who needed to find a personal doctor or nurse, needed to
see a specialist, or needed to schedule an appointment.
[End of table]
Beneficiary Perceptions of Major Access Difficulties Varied by State,
but Trends over Time Were Stable or Improved:
In each survey year, the proportion of beneficiaries who reported major
difficulties accessing physician services varied considerably across
the 50 states and the District of Columbia. For example, in 2004,
Alaska had the highest proportion of beneficiaries--15 percent--who
reported having a big problem finding a personal doctor or nurse,
whereas Nebraska had the lowest, 3 percent. Figure 1 shows variation
among the states in the percentage of beneficiaries who reported having
a big problem finding a personal doctor or nurse in 2004. Also in 2004,
the percentage who reported having a big problem seeing a specialist
ranged from a high of 11 percent in Alaska to a low of 2 percent in
Vermont. In contrast, the proportion of beneficiaries who reported
never being able to schedule an appointment promptly had a smaller
range--from a high of 5 percent in Alaska to less than 1 percent in
Nebraska. In a separate analysis, we found that the supply of health
care resources, such as physicians and hospital beds, did not have a
sufficiently important impact on beneficiaries' perceptions of access
to physician services; the variation we found among states in the
percentages reporting major difficulties should therefore not be
interpreted as being related to the availability of health care
resources. (See app. I.)
Figure 1: Variation by State in Percentage of Medicare Beneficiaries
Who Reported Having a Big Problem Finding a Personal Doctor or Nurse,
2004:
[See PDF for image]
Source: GAO analysis of CMS's Medicare CAHPS survey.
Note: Percentages are reported only for beneficiaries who indicated in
their survey responses that they had a different personal doctor than
before they enrolled in Medicare.
[End of Figure]
In the vast majority of states, the proportion of beneficiaries in 2004
who reported major difficulties accessing physician services was nearly
the same as, or lower than, the proportion in 2000. Specifically, in 49
states, the proportion of beneficiaries in each state who reported a
big problem finding a personal doctor or nurse either stayed the same-
-within 2 percentage points of that reported in 2000--or fell by more
than 2 percentage points.[Footnote 37] (See fig. 2.) Similarly, in all
50 states and the District of Columbia, the proportion of beneficiaries
who reported a big problem seeing a specialist either stayed the same
or declined. In 47 states, proportions of beneficiaries who reported
never being able to schedule an appointment promptly remained the
same.[Footnote 38]
Figure 2: Percentage Point Change in Medicare Beneficiary Reports of
Having a Big Problem Finding a Personal Doctor or Nurse, 2000 to 2004:
[See PDF for image]
Source: GAO analysis of CMS's CAHPS survey.
Note: Percentage point changes are reported only for beneficiaries who
indicated in their survey responses that they had a different personal
doctor than before they enrolled in Medicare.
[End of Figure]
The District of Columbia and Idaho were exceptional in that
beneficiaries' perceptions of access grew worse from 2000 to 2004 on
more than one question. Specifically, during that period, the
proportion of beneficiaries in the District of Columbia who reported a
big problem finding a personal doctor or nurse increased by 7
percentage points, and the proportion who reported never having
scheduled an appointment promptly increased by 3 percentage points.
Over the same period, the proportions of beneficiaries in Idaho who
reported a big problem finding a personal doctor or nurse and who
reported never having scheduled an appointment promptly increased by 2
percentage points.
Beneficiary Perceptions of Major Access Difficulties Were Similar for
Urban and Rural Areas:
We observed very little difference between the proportions of urban and
rural beneficiaries who reported major difficulties accessing physician
services during the period 2000 through 2004. For example, in 2004, 5.5
percent of urban beneficiaries reported having a big problem finding a
personal doctor or nurse, and 4.8 percent of rural beneficiaries
reported a big problem. In that same year, 4.4 percent of urban
beneficiaries and 4.1 percent of rural beneficiaries reported having a
big problem finding a specialist. Similarly, 1.6 percent of urban
beneficiaries reported never being able to schedule an appointment
promptly, and 1.4 percent of rural beneficiaries reported this
difficulty.
The proportions of both urban and rural beneficiaries who reported
major access difficulties remained relatively stable--changing by no
more than 2 percentage points--from 2000 through 2004. For example, the
proportion of urban beneficiaries who reported having a big problem
finding a personal doctor or nurse ranged from a high of 7.3 percent in
2000 to a low of 5.5 percent in 2004. Similarly, the proportion of
beneficiaries in rural areas who reported a big problem ranged from a
high of 6.7 percent in 2000 to a low of 4.8 percent in 2004. When asked
about seeing a specialist, the percentage of urban beneficiaries who
reported having a big problem was 5.6 in 2000 and 4.4 in 2004.
Likewise, 5.4 percent of rural beneficiaries reported having a big
problem in 2000, as did 4.1 percent in 2004. Finally, the proportion of
urban beneficiaries who reported never being able to schedule an
appointment promptly was relatively stable--1.2 percent in 2000 and 1.6
percent in 2004. Among rural beneficiaries, 1.0 percent and 1.4 percent
reported this difficulty in 2000 and 2004, respectively.
Beneficiaries with Certain Characteristics More Likely Than Others to
Report Major Access Difficulties:
Beneficiaries with certain characteristics--fair or poor self-reported
health status, under age 65, nonwhite, no supplemental health insurance
or supplemental insurance from Medicaid, college-educated--were
somewhat more likely than other beneficiaries to report major
difficulties accessing physician services.[Footnote 39] For example,
when asked about their ability to find a personal doctor or nurse they
were happy with, on average over the 5 years, about 8 percent of
beneficiaries in fair or poor health responded that they had a big
problem, compared with about 4 percent of beneficiaries in excellent or
very good health.[Footnote 40] (See table 3.) On the other two
physician access questions, those in fair or poor health similarly
reported major difficulties more frequently on average than those in
better health.[Footnote 41] This relationship between health status and
reported access is consistent with the fact that people in fair or poor
health are likely to have more physician encounters and thus have more
opportunities to experience an access problem.
Table 3: Average Percentage of Medicare Beneficiaries Who Reported
Major Difficulties Accessing Physician Services by Self-Reported Health
Status, 2000-2004:
Beneficiary self-reported health status: Excellent or very good;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 4.1;
Percentage reporting a big problem seeing a specialist[B]: 2.5;
Percentage reporting never being able to schedule an appointment
promptly[C]: 1.2.
Beneficiary self-reported health status: Good;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 4.8;
Percentage reporting a big problem seeing a specialist[B]: 3.4;
Percentage reporting never being able to schedule an appointment
promptly[C]: 1.2.
Beneficiary self-reported health status: Fair or poor;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 8.0;
Percentage reporting a big problem seeing a specialist[B]: 7.2;
Percentage reporting never being able to schedule an appointment
promptly[C]: 1.6.
Source: GAO analysis of CMS's Medicare CAHPS surveys.
[A] Percentages are reported for beneficiaries who reported that they
did not have the same personal doctor or nurse before joining Medicare.
[B] Percentages are reported for beneficiaries who reported needing to
see a specialist in the past 6 months.
[C] Percentages are reported for beneficiaries who reported needing to
make an appointment in the past 6 months.
[End of table]
Compared with respondents age 65 and over, a larger proportion of
beneficiaries under age 65, who typically qualify for Medicare on the
basis of disability,[Footnote 42] reported major difficulties accessing
physician services. For example, on average during this period, about
11 percent of beneficiaries under age 65 reported a big problem seeing
a specialist, compared with 4 percent of beneficiaries over age
65.[Footnote 43] (See table 4.) This relationship suggests that
disabled beneficiaries were more likely to report having major
physician access difficulties than beneficiaries age 65 and older.
Table 4: Average Percentage of Medicare Beneficiaries Who Reported
Having Major Difficulties Accessing Physician Services by Beneficiary
Age Group, 2000-2004:
Beneficiary age group: Under 65;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 13.2;
Percentage reporting a big problem seeing a specialist[B]: 10.8;
Percentage reporting never being able to schedule an appointment
promptly[C]: 2.5.
Beneficiary age group: 65 and over[D];
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 5.1;
Percentage reporting a big problem seeing a specialist[B]: 4.0;
Percentage reporting never being able to schedule an appointment
promptly[C]: 1.2.
Source: GAO analysis of CMS's Medicare CAHPS surveys.
[A] Percentages are reported for beneficiaries who did not have the
same personal doctor or nurse before they joined Medicare.
[B] Percentages are reported for beneficiaries who indicated that they
needed to see a specialist in the past 6 months.
[C] Percentages are reported for beneficiaries who attempted to make an
appointment in the past 6 months.
[D] Across the age breakouts for those age 65 and over--that is, 65 to
69, 70 to 74, 75 to 79, 80 to 84, and 85 and over--the percentage
reporting having major difficulties varied little.
[End of table]
Nonwhite beneficiaries were somewhat more likely to report major
difficulties accessing physician services than white beneficiaries. For
example, the percentage of nonwhites reporting a big problem finding a
personal doctor or nurse, on average, was about 2 percentage points
higher relative to whites. In addition, the percentages of nonwhites
reporting major difficulties accessing specialists and scheduling
appointments were larger on average than the percentages of whites
reporting major difficulties--a difference of 6 and 1 percentage
points, respectively.[Footnote 44] (See table 5.)
Table 5: Average Percentage of Medicare Beneficiaries Who Reported
Having Major Difficulties Accessing Physician Services by Race, 2000-
2004:
Beneficiary race: White;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 5.7;
Percentage reporting a big problem seeing a specialist[B]: 4.1;
Percentage reporting never being able to schedule an appointment
promptly[C]: 1.2.
Beneficiary race: Black;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 6.4;
Percentage reporting a big problem seeing a specialist[B]: 8.9;
Percentage reporting never being able to schedule an appointment
promptly[C]: 2.1.
Beneficiary race: Hispanic;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 8.2;
Percentage reporting a big problem seeing a specialist[B]: 11.3;
Percentage reporting never being able to schedule an appointment
promptly[C]: 2.4.
Beneficiary race: Other;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 9.3;
Percentage reporting a big problem seeing a specialist[B]: 11.2;
Percentage reporting never being able to schedule an appointment
promptly[C]: 2.4.
Beneficiary race: All nonwhite;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 7.5;
Percentage reporting a big problem seeing a specialist[B]: 10.1;
Percentage reporting never being able to schedule an appointment
promptly[C]: 2.3.
Source: GAO analysis of CMS's Medicare CAHPS surveys.
[A] Percentages are reported for beneficiaries who did not have the
same personal doctor or nurse before they joined Medicare.
[B] Percentages are reported for beneficiaries who indicated that they
needed to see a specialist in the past 6 months.
[C] Percentages are reported for beneficiaries who attempted to make an
appointment in the past 6 months.
[End of table]
Medicare beneficiaries with no supplemental health insurance and those
with Medicaid as a supplement were more likely than beneficiaries with
only Medigap or other non-Medicaid supplemental health insurance to
report major difficulties accessing physician services. For example, on
average, beneficiaries with no supplemental coverage or with Medicaid
were about 2 and about 4 percentage points, respectively, more likely
than beneficiaries with only non-Medicaid supplemental coverage to
report a big problem finding a personal doctor or nurse. (See table 6.)
With respect to seeing a specialist, beneficiaries with no supplemental
health insurance or Medicaid were, on average, about 5 and 6 percentage
points respectively, more likely to report a big problem, compared with
beneficiaries with non-Medicaid supplemental coverage. Beneficiaries
with no supplemental coverage or Medicaid were about 1 percentage point
more likely than those with other supplemental coverage to report never
being able to schedule an appointment promptly.[Footnote 45]
Table 6: Average Percentage of Medicare Beneficiaries Who Reported
Having Major Difficulties Accessing Physician Services by Supplemental
Health Insurance Coverage, 2000-2004:
Supplemental health insurance coverage: None;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 7.5;
Percentage reporting a big problem seeing a specialist[B]: 8.9;
Percentage reporting never being able to schedule an appointment
promptly[C]: 2.1.
Supplemental health insurance coverage: Medicaid;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 8.8;
Percentage reporting a big problem seeing a specialist[B]: 9.2;
Percentage reporting never being able to schedule an appointment
promptly[C]: 1.8.
Supplemental health insurance coverage: Non-Medicaid;
Percentage reporting a big problem finding a personal doctor or nurse
they were happy with[A]: 5.1;
Percentage reporting a big problem seeing a specialist[B]: 3.6;
Percentage reporting never being able to schedule an appointment
promptly[C]: 1.1.
Source: GAO analysis of CMS's Medicare CAHPS surveys.
Note: Non-Medicaid includes supplemental coverage from the Department
of Veterans Affairs, Tricare, Medigap, and other private insurance.
Some beneficiaries included in the Medicaid supplemental category may
also have had non-Medicaid supplemental coverage.
[A] Percentages are reported for beneficiaries who did not have the
same personal doctor or nurse before they joined Medicare.
[B] Percentages are reported for beneficiaries who indicated that they
needed to see a specialist in the past 6 months.
[C] Percentages are reported for beneficiaries who attempted to make an
appointment in the past 6 months.
[End of table]
After we controlled for the other factors that could affect access to
physician services,[Footnote 46] including health status, age, and
race, beneficiaries who had a 4-year college degree were more likely to
report major difficulties accessing physician services. (See app. I.)
For example, a typical beneficiary--a white female, age 70 to 74, with
a high school diploma--had about a 7 percent likelihood of reporting a
big problem finding a personal doctor or nurse.[Footnote 47] In
contrast, if the same beneficiary had attained a 4-year college degree,
she would have slightly more than an 8 percent likelihood of reporting
a big problem finding a personal doctor or nurse.
From 2000 to 2005, Both Proportion of Beneficiaries Receiving Physician
Services and Number of Services Provided per Beneficiary Increased:
Two indicators of beneficiary access to physician services--the
proportion of beneficiaries who received services and the number of
services provided to beneficiaries who were treated--suggest an
increase in access from April 2000 to April 2005. Nationwide, in urban
areas and in rural areas, the proportion of beneficiaries receiving
services rose by 3 to 4 percentage points over this period. Moreover,
the average number of services provided per 1,000 beneficiaries who
received services rose nationwide by 14 percent, in urban areas by 15
percent, and in rural areas by 12 percent. These two indicators
increased within every state's urban areas and almost every state's
rural areas.
Proportion of Beneficiaries Receiving Physician Services Grew:
In general, the proportion of beneficiaries who received physician
services rose during the period covered in our review. (See fig. 3.)
Specifically, from 2000 to 2005, the proportion of beneficiaries
receiving services during the month of April rose from about 41 percent
to about 45 percent. Although this measure declined slightly in April
2003, the proportion of beneficiaries receiving services remained a
percentage point higher than in April 2000 and the upward trend resumed
in 2004. Nationwide, this measure increased in both urban and rural
areas. Specifically, the proportion of beneficiaries receiving services
rose from about 42 percent in April 2000 to about 46 percent in April
2005 in urban areas and from about 39 percent in April 2000 to about 42
percent in April 2005 in rural areas.
Figure 3: Percentage of Medicare Beneficiaries Receiving Physician
Services in April, 2000-2005:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Note: Beneficiaries were included if they received a service in the
first 28 days of April.
[End of figure]
In each year, the proportions of beneficiaries receiving services in
April varied by state urban and rural areas. (See fig. 4.) For example,
in 2005, the lowest proportion of beneficiaries receiving services was
33 percent in urban Alaska, whereas the highest proportion was 53
percent in rural Delaware. The proportion of beneficiaries receiving
services in April 2005 was 40 percent or higher in almost three-
quarters of the 99 urban and rural areas we examined.[Footnote 48]
Specifically, within the states, in four-fifths of the urban areas and
two-thirds of the rural areas, the proportion of beneficiaries
receiving services was 40 percent or more.
Figure 4: Variation by State Urban and Rural Areas in Proportion of
Medicare Beneficiaries Receiving Physician Services, April 2005:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Note: Beneficiaries were included if they received a service in the
first 28 days of April.
[End of figure]
Within every state's urban areas and almost every state's rural areas,
the proportion of beneficiaries receiving services increased from April
2000 to April 2005. The percentage of beneficiaries receiving services
increased by 4 percentage points in urban areas and by 3 percentage
points in rural areas. There was a slight decline--1 percentage point
or less--in the rural areas of Hawaii and Washington. (See fig. 5.) The
largest increase--14 percentage points--occurred in rural Alaska. In
two-thirds of the 99 areas we examined, there was at least a 3
percentage point increase from April 2000 to April 2005.
Figure 5: Percentage Point Change from 2000 to 2005 in Proportion of
Medicare Beneficiaries Receiving Physician Services in April, by State
Urban and Rural Areas:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims data from CMS.
Note: Beneficiaries were included if they received a service in the
first 28 days of April.
[End of figure]
Average Number of Services Provided Rose:
From April 2000 to April 2005, an increasing number of services were
provided to beneficiaries who were treated by a physician.
Specifically, in that period, the average number of services provided
per 1,000 beneficiaries who were treated rose by 14 percent--from about
3,400 to about 3,900. From April 2000 to April 2005, the number of
services provided per 1,000 beneficiaries was lower in rural areas
(3,196 services per 1,000 beneficiaries who received services in 2000)
relative to urban areas (3,516 services per 1,000 beneficiaries who
received services in 2000). (See fig. 6.) However, in percentage terms,
the urban and rural areas experienced similar increases in the number
of services per treated beneficiary--15 percent in urban areas,
compared with 12 percent in rural areas.
Figure 6: Number of Physician Services Provided per 1,000 Medicare
Beneficiaries Served in April, 2000-2005:
[See PDF for image]
Source: GAO analysis of Medicare part B claims and enrollment data from
CMS.
Note: Beneficiaries and services were included if services were
received in the first 28 days of April.
[End of figure]
The number of services provided also varied among states' urban areas
and rural areas. (See fig. 7.) For example, in April 2005, the lowest
number of services provided per 1,000 beneficiaries who were treated by
a physician was 3,071 services in urban Vermont, whereas the highest
number was 4,503 services in urban Florida. In rural areas, the number
ranged from 3,094 services in Vermont to 4,191 in Florida.
Figure 7: Variation by State Urban and Rural Areas in the Average
Number of Physician Services Provided per 1,000 Medicare Beneficiaries
Served, April 2005:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims data from CMS.
Note: Beneficiaries and services were included if services were
received in the first 28 days of April.
[End of figure]
Within every state's urban and rural areas, there was an increase from
April 2000 to April 2005 in the average number of services provided for
each beneficiary who was treated by a physician. (See fig. 8.) In 57 of
the 99 areas we examined, the number of services provided per 1,000
beneficiaries increased by at least 12 percent. Among the 51 urban
areas we examined, the percentage increase in the number of services
provided per 1,000 beneficiaries ranged from a high of 21 percent in
New York to a low of 3 percent in Vermont. Among the 48 rural areas,
the increase ranged from a high of 20 percent in Connecticut to a low
of 4 percent in Wyoming.
Figure 8: Change from 2000 to 2005 in Number of Physician Services
Provided per 1,000 Medicare Beneficiaries in April, by State Urban and
Rural Areas:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims data from CMS.
Note: Beneficiaries and services were included if the services were
received in the first 28 days of April.
[End of figure]
Although the CAHPS survey showed a worsening in beneficiaries'
perceptions of access to physician services in two states--the District
of Columbia and Idaho--our analysis of the claims data demonstrated
that the number of services provided to Medicare beneficiaries
increased in both states and increased substantially in one of the two
states. For example, from April 2000 to April 2004, the same period
covered by the CAHPS surveys, we found a double-digit increase in the
number of services provided per capita both nationwide (24 percent) and
in Idaho (13 percent).[Footnote 49] In contrast, over the same period,
the number of services provided per capita increased by only 2 percent
in the District of Columbia. (See fig. 9.)
Figure 9: Number of Physician Services Provided per 1,000 Medicare
Beneficiaries in April, 2000 and 2004:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Notes: Services were included if they were received in the first 28
days of April. We focused on the two states identified by our analysis
of CAHPS data as showing a worsening access problem from 2000 to 2004.
[End of figure]
In examining trends in the number, or volume, of services, we found
that volume generally increased across broad categories of services--
evaluation and management, procedures, imaging services, and tests.
Specifically, the number of services provided per 1,000 Medicare
beneficiaries increased in all of these categories from April 2000 to
April 2005. (See fig. 10.) Within the procedures category, the number
of minor procedures provided per 1,000 beneficiaries increased by 36
percent, whereas the number of major procedures declined slightly by 3
percent.
Figure 10: Number of Services Provided per 1,000 Medicare Beneficiaries
in April, by Service Category, 2000 and 2005:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Note: Services were included if they were received in the first 28 days
of April.
[End of figure]
In examining trends in the numbers of services provided, we also found
that the average number of office visits--an indicator of access to the
most basic level of physician services--generally increased (see fig.
11).[Footnote 50] Specifically, from 2000 to 2005, the number of office
visits per 1,000 Medicare beneficiaries received during the month of
April increased from 26 visits to 28 visits for new patients (an
increase of about 8 percent) and from 405 visits to 454 visits for
established patients (an increase of about 12 percent).[Footnote 51]
Figure 11: Number of Office Visits per 1,000 Medicare Beneficiaries in
April by New and Established Patients, 2000-2005:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims data from CMS.
Notes: Services were included if they were received in the first 28
days of April. Medicare defines an established patient as one who has
seen the same physician at least once before in the past 3 years.
[End of figure]
We also found that the number of specialty services provided generally
increased over the 6 years reviewed. Most of the specialty services we
examined--such as aneurysm repairs, pacemaker insertions, and hip
replacements--experienced double-digit growth rates. (For a complete
list of the services we examined, see app. III.) For example, per
capita growth in aneurysm repairs rose by about 65 percent; in
pacemaker insertions, by about 64 percent; and in hip replacements, by
about 11 percent. Moreover, we found double-digit per capita growth
rates over the 6 years reviewed for services that are most likely to be
affected by physician fee changes. These discretionary services could
be postponed without medically harming the patient, and therefore
physicians might provide fewer of them when there is downward pressure
on fees. For example, per capita growth in knee replacement procedures
rose by about 47 percent; in electrocardiograms, by about 18 percent;
and in CAT scans, by about 65 percent. Although per capita declines
occurred for a few specialty procedures,[Footnote 52] these declines
may have resulted for reasons other than access difficulties, such as
physician discretion, patient acuity, or the ability to substitute
other procedures. For example, coronary artery bypass grafting (CABG)
declined per beneficiary by about 31 percent, whereas coronary
angioplasty, a substitute in some cases for CABG, grew per beneficiary
by about 34 percent.
Complexity of Services Provided Also Increased:
Service complexity--an element of utilization--increased from April
2000 to April 2005. Specifically, physician services per beneficiary
rose in complexity, as measured in average annual changes in RVUs, over
this period. Increases in service volume occurred for each broad
category of services--evaluation and management, procedures, imaging,
and tests--with the exception of major procedures. Similarly, for all
categories of services, the complexity of services provided per
beneficiary rose over the same period. (See table 7.) Overall, volume
rose by an average of about 4 percent, while complexity rose by an
average of about 5 percent. Thus, beneficiaries' increased utilization
of physician services has manifested itself in both increased volume
and increased complexity of services for the 6 years reviewed.
Table 7: Changes in Volume and Complexity of Physician Services
Provided per Medicare Beneficiary, April 2000-April 2005:
Type of service: All services;
Annual percentage change in number of services per beneficiary, April
2000-April 2005: 4.4;
Annual percentage change in complexity of services per beneficiary, as
measured in RVUs, April 2000-April 2005: 5.2.
Type of service: Evaluation and management services;
Annual percentage change in number of services per beneficiary, April
2000-April 2005: 2.4;
Annual percentage change in complexity of services per beneficiary, as
measured in RVUs, April 2000-April 2005: 3.7.
Type of service: Procedures;
Annual percentage change in number of services per beneficiary, April
2000-April 2005: 5.7;
Annual percentage change in complexity of services per beneficiary, as
measured in RVUs, April 2000-April 2005: 4.3.
Type of service: Major;
Annual percentage change in number of services per beneficiary, April
2000-April 2005: -0.7;
Annual percentage change in complexity of services per beneficiary, as
measured in RVUs, April 2000-April 2005: 2.3.
Type of service: Minor;
Annual percentage change in number of services per beneficiary, April
2000-April 2005: 6.3;
Annual percentage change in complexity of services per beneficiary, as
measured in RVUs, April 2000-April 2005: 5.2.
Type of service: Imaging;
Annual percentage change in number of services per beneficiary, April
2000-April 2005: 6.9;
Annual percentage change in complexity of services per beneficiary, as
measured in RVUs, April 2000-April 2005: 10.5.
Type of service: Tests;
Annual percentage change in number of services per beneficiary, April
2000-April 2005: 9.1;
Annual percentage change in complexity of services per beneficiary, as
measured in RVUs, April 2000-April 2005: 13.9.
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Notes: Services were included in the calculation of average annual
percentage changes if the services were received in the first 28 days
of April. To account for complexity of services, we used RVU weights
for 2005.
[End of table]
From 2000 to 2005, Indicators of Physician Supply and Willingness to
Serve Medicare Beneficiaries Were 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 from 2000
to 2005. These increases suggest that in the aggregate, physicians
continued to accept Medicare patients without requiring additional
payments from beneficiaries during this period.
Number of Physicians Serving Medicare Beneficiaries Increased:
An increasing number of physicians billed Medicare from April 2000 to
April 2005. (See fig. 12.) In April 2000, the number of physicians
billing Medicare was about 419,000, and in April 2005, that number had
increased to a little more than 467,000. While Medicare experienced an
11 percent increase in the number of physicians billing the program,
the number of beneficiaries in Medicare--FFS and managed care combined-
-rose by 8 percent.[Footnote 53]
Figure 12: Number of Physicians Billing Medicare for Services Provided
to Medicare Beneficiaries in April, 2000-2005:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims data from CMS.
Notes: Physicians were included if they served a beneficiary in the
first 28 days of April. We counted each occurrence of the unique
physician identification number on the claim once.
[End of figure]
Proportion of Services for Which Physicians Accepted Medicare Payment
in Full Increased:
From April 2000 to April 2005, the vast majority of Medicare physician
services were performed by participating physicians--that is,
physicians who formally agreed to participate in the Medicare program
and submit all claims on assignment.[Footnote 54] This percentage
increased from 95 percent to over 96 percent. (See fig. 13.) During the
same period, the overall percentage of services paid on assignment--
that is, services performed by both participating and nonparticipating
physicians who accepted assignment--also increased. In April 2000, 98.2
percent of services were paid on assignment, and in April 2005, 99.0
percent of services were paid on assignment. Fewer beneficiaries were
likely to be subject to balance billing for physician services in 2005
than in 2000 as the percentage of services for which physicians were
permitted to balance bill Medicare beneficiaries fell from 1.8 percent
to 1.0 percent.
Figure 13: Proportion of Physician Services by Medicare Participation
and Assignment Status, April 2000 and April 2005:
[See PDF for image]
Source: GAO analysis of Medicare Part B claims data from CMS.
Note: Services were included if they were received in the first 28 days
in April.
[End of figure]
Concluding Observations:
Although concerns have been raised that Medicare's efforts to control
spending on physician services might have diminished beneficiary access
to those services, our analyses of data from 2000 through 2005 found
access to physician services stayed the same or increased.
Specifically, during the years we studied, relatively small proportions
of beneficiaries reported problems accessing physician services, the
percentage of beneficiaries who received physician services increased,
and the number of services provided per beneficiary increased. Finally,
our indicators of physician willingness to serve Medicare
beneficiaries--the number of physicians billing Medicare and the
proportion of services for which physicians accepted Medicare payment
in full--help round out the picture of beneficiary access to services.
We found that during the 2000-2005 period covered by our claims
analysis, an increasing number of physicians billed Medicare and an
increasing number of claims were submitted "on assignment." The general
stability in perceptions of access problems and increases in other
indicators of access are notable, considering that during all but 2 of
the years examined, annual updates caused physician fees either to fall
or to increase at rates below the increase in the estimated cost of
providing services.
The increases in utilization and complexity we observed demonstrate
that beneficiaries were able to access physician services. However, we
did not determine the medical appropriateness of these increases. A
more complex study would be required to determine whether the increased
utilization over the period we studied resulted in positive health
outcomes for beneficiaries. Such analysis is important because these
utilization trends have implications for the long-term fiscal
sustainability of the Medicare program.
Agency and Industry Comments and Our Evaluation:
Agency Comments:
In written comments on a draft of this report, CMS agreed with our
findings and conclusions, stating that our analysis of existing data
was well-conceived and executed. CMS noted the agency's commitment to
ensuring continued beneficiary access to care while attempting to
address the long-term fiscal sustainability of the Medicare program.
CMS said that it had conducted its own analyses of data from a variety
of sources in order to identify any beneficiary difficulties in
accessing physician services, and these analyses did not indicate a
national problem accessing care. CMS noted that we may want to include
claims reflecting services performed in federally qualified health
centers (FQHC) and rural health clinics (RHC) in any future analyses of
utilization, as relying solely upon Part B claims from the National
Claims History files may underrepresent utilization of physician
services. However, the agency stated that including these claims would
not substantively change GAO's results and conclusions. Furthermore, we
note that our utilization measures would change only to the extent that
services provided in FQHCs and RHCs were performed by medical doctors,
as we excluded services performed by nonphysicians, such as nurse
practitioners and physician assistants. CMS also provided other
comments it characterized as minor editorial and technical points,
which we incorporated where appropriate. We have reprinted CMS's letter
in appendix IV.
American Medical Association Comments:
We obtained oral comments on our draft report from officials
representing the AMA. The AMA officials expressed two overall concerns.
First, while stating that our analysis of survey, claims, and physician
participation data showed no deterioration in beneficiaries' access to
physician services over the period studied, the officials cautioned the
analyses' results should not be interpreted as an improvement in
access. The AMA officials said that for example, increases in the
utilization of physician services could be the result of beneficiaries
growing sicker, the substitution of physician services for care in the
hospital or other settings, or beneficiaries taking advantage of new
Medicare-covered benefits. An investigation of alternate explanations
for the growth in utilization was beyond the scope of this report.
Although our report finds that the percentage of beneficiaries
reporting major access difficulties remained relatively constant over
the period, that the utilization of services generally increased
nationwide, and that physician participation in Medicare also
increased, the report does not characterize these findings as
improvements in access. Second, the AMA officials said that the report
should place more emphasis on our finding that beneficiaries with
certain characteristics, such as those in poor health, were more
likely, than to other beneficiaries, to respond that they experienced
major difficulty accessing physician services. Although this finding is
not the focus of our report, we believe that it is accorded the
appropriate emphasis, as it is included in the Highlights section and
the Results in Brief. Based on other comments from AMA officials, we
revised our draft report where appropriate.
We are sending copies of this report to the Administrator of CMS,
appropriate congressional committees, and other interested parties. We
will also provide copies to others on request. In addition, this report
is available at no charge on the GAO Web site at [Hyperlink,
http://www.gao.gov].
If you or your staff have questions about this report, please contact
me at (202) 512-7101 or steinwalda@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to
this report are listed in appendix V.
Signed by:
A. Bruce Steinwald:
Director, Health Care:
List of Committees:
The Honorable Charles E. Grassley:
Chairman:
The Honorable Max Baucus:
Ranking Minority Member:
Committee on Finance:
United States Senate:
The Honorable Joe L. Barton:
Chairman:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable William M. Thomas:
Chairman:
The Honorable Charles B. Rangel:
Ranking Minority Member:
Committee on Ways and Means:
House of Representatives:
The Honorable Nathan Deal:
Chairman:
The Honorable Sherrod Brown:
Ranking Minority Member:
Subcommittee on Health Committee on Energy and Commerce:
House of Representatives:
The Honorable Nancy L. Johnson:
Chairman:
The Honorable Pete Stark:
Ranking Minority Member:
Subcommittee on Health:
Committee on Ways and Means:
House of Representatives:
[End of section]
Appendix I: Methods and Models Used in Analyzing Factors Affecting
Medicare Beneficiaries' Perceptions of Access:
This appendix explains how we analyzed beneficiaries' perceptions of
their ability to access physician services and factors that might
contribute to those perceptions. First, we describe the data we
analyzed from the Medicare Consumer Assessment of Health Plan Study
(CAHPS), which contains indicators of fee-for-service (FFS) beneficiary
perceptions of physician access. Next, we explain how we identified
beneficiaries' characteristics that were associated with their
perceptions of access to physician services. We then describe how we
reported the way those beneficiary characteristics were associated with
major difficulties accessing physician services. We also explain how we
identified trends in beneficiary perceptions over time and across
states. Finally, we discuss how we evaluated the reliability of our
data and the limitations of our analysis.
Data Sources:
To study beneficiaries' perceived access to physician services, we used
data from the Centers for Medicare & Medicaid Services' (CMS) CAHPS FFS
annual surveys administered from 2000 through 2004. The CAHPS survey
asks beneficiaries to describe their experiences with the Medicare FFS
program. We identified these annual surveys as a nationally
representative source of Medicare beneficiaries' perceptions of their
access to health care that would enable comparisons over time among
states and between urban and rural areas. CMS surveyed over 168,000 FFS
beneficiaries each year.[Footnote 55] The response rate was at least 63
percent each year.
We focused on the three CAHPS questions that were related to
beneficiaries' access to physician services. The questions, reproduced
in table 8, asked about beneficiaries' ability to access a personal
provider of care (a physician or nurse), specialists, and prompt
appointments. For each question, we included only the responses from
those beneficiaries who could have encountered an access problem--those
who reported in a prior question that they in fact needed
care.[Footnote 56] 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 had "a big problem" or
who "never" scheduled a prompt appointment. This approach enabled us to
be as definitive as possible in describing beneficiaries perceptions of
access difficulties.[Footnote 57]
Table 8: CAHPS Survey Questions Related to Physician Access, 2000-2004:
Respondents included in analysis: Beneficiaries who reported that they
did not have the same doctor before joining Medicare;
Percentage of all survey respondents: 47;
Access question: Since you joined Medicare, how much of a problem, if
any, was it to get a personal doctor or nurse you are happy with?;
Response:
* A big problem;
* A small problem;
* Not a problem.
Respondents included in analysis: Beneficiaries who reported that they
needed to see a specialist in the past 6 months;
Percentage of all survey respondents: 56;
Access question: In the past 6 months, how much of a problem, if any,
was it to see a specialist that you needed to see?;
Response:
* A big problem;
* A small problem;
* Not a problem.
Respondents included in analysis: Beneficiaries who reported that they
needed to schedule a routine health care appointment in the past 6
months;
Percentage of all survey respondents: 74;
Access question: In the past 6 months, how often did you get an
appointment for health care as soon as you wanted?;
Response:
* Never;
* Sometimes;
* Usually;
* Always.
Source: GAO analysis of CMS's annual Medicare CAHPS surveys.
Note: The exact wording of each question varied by survey year.
[End of table]
The CAHPS survey also asked beneficiaries to provide information about
themselves, and we used those responses to determine whether
beneficiary characteristics were systematically associated with
beneficiaries reporting major difficulties accessing physician
services. Specifically, we analyzed beneficiary sex, race, age,
educational attainment, urban or rural residence, additional health
care coverage, and self-reported health status.[Footnote 58] We
supplemented the CAHPS data for each beneficiary with county-level
information from the 2000 Area Resource File (ARF)[Footnote 59] on
primary care physicians per capita, specialist physicians per capita,
managed care penetration, per capita income, the proportion of the
population enrolled in Medicare, hospital beds per capita, and
ambulatory surgical centers per Medicare beneficiary.[Footnote 60]
Analysis of Beneficiary Responses to the CAHPS Survey:
To analyze the extent to which various beneficiary and area
characteristics were associated with perceived access to physician
services, we first used a standard statistical method of analysis known
as logistic regression modeling to identify key beneficiary and area
characteristics, and then we computed simple proportions of
beneficiaries with key characteristics who reported major difficulties.
For example, our model showed that age was associated with reporting
major difficulties, so we reported percentages reporting major
difficulties by age group. Logistic regression modeling estimates the
effect of each independent variable--in this case, a beneficiary
characteristic--on an either/or (binary) variable--in this case, either
reporting a major difficulty or not--while holding constant the effects
of other independent variables in the model. The size of the effect of
each beneficiary characteristic is expressed as a coefficient, which
can be mathematically converted into an odds ratio. The odds ratio
compares the likelihood of reporting a major difficulty when a
characteristic is present to the likelihood of reporting a major
difficulty when the characteristic is absent. When a characteristic is
absent, the beneficiary is classified as belonging to a "reference
group." For example, for the characteristic "race," our logistic
regression model compares three race variables--black, Hispanic, and
other race--to the reference group, white. (See table 9.) The odds
ratio of the reference group is always set equal to 1.00. Odds ratios
larger than 1.00 indicate that the presence of the characteristic
increases the likelihood of reporting a major difficulty compared to
the reference group, while odds ratios smaller than 1.00 indicate that
the presence of the characteristic decreases the likelihood of
reporting a major difficulty compared to the reference group. We
combined observations from all 5 CAHPS survey years in the logistic
regression analysis.[Footnote 61] The logistic regression models for
the three access questions included variables for 15 beneficiary and
area characteristics, which are listed, together with their odds
ratios, in table 9.
Table 9: Estimated Effects of Selected Medicare Beneficiary and Area
Characteristics on Reporting Major Difficulty Accessing Physician
Services, 2000-2004:
Age;
Characteristic: Under 65;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Age;
Characteristic: : 65-69;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.63**;
Odds ration: Big problem seeing a specialist[B]: 0.61**;
Odds ration: Never scheduled an appointment promptly[C]: 0.77**.
Age;
Characteristic: : 70-74;
Odds ration: Big problem finding a personal doctor or nurse[A]:
0.51**;
Odds ration: Big problem seeing a specialist[B]: 0.58**;
Odds ration: Never scheduled an appointment promptly[C]: 0.56**.
Age;
Characteristic: : 75-79;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.43**;
Odds ration: Big problem seeing a specialist[B]: 0.55**;
Odds ration: Never scheduled an appointment promptly[C]: 0.55**.
Age;
Characteristic: : 80-84;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.36**;
Odds ration: Big problem seeing a specialist[B]: 0.55**;
Odds ration: Never scheduled an appointment promptly[C]: 0.53**.
Age;
Characteristic: 85 and over;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.30**;
Odds ration: Big problem seeing a specialist[B]: 0.52**;
Odds ration: Never scheduled an appointment promptly[C]: 0.56**.
Sex;
Characteristic: Female;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Sex;
Characteristic: Male;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.84**;
Odds ration: Big problem seeing a specialist[B]: 0.93*;
Odds ration: Never scheduled an appointment promptly[C]: 1.21**.
Race;
Characteristic: White;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Race;
Characteristic: Black;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.83**;
Odds ration: Big problem seeing a specialist[B]: 1.38**;
Odds ration: Never scheduled an appointment promptly[C]: 1.28**.
Race;
Characteristic: Hispanic;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.09;
Odds ration: Big problem seeing a specialist[B]: 1.86**;
Odds ration: Never scheduled an appointment promptly[C]: 1.50**.
Race;
Characteristic: Other;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.28**;
Odds ration: Big problem seeing a specialist[B]: 2.14**;
Odds ration: Never scheduled an appointment promptly[C]: 1.64**.
Self-reported health status;
Characteristic: Excellent or very good;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.80**;
Odds ration: Big problem seeing a specialist[B]: 0.75**;
Odds ration: Never scheduled an appointment promptly[C]: 0.99.
Self-reported health status;
Characteristic: Good;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Self-reported health status;
Characteristic: Fair or poor;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.57**;
Odds ration: Big problem seeing a specialist[B]: 1.80**;
Odds ration: Never scheduled an appointment promptly[C]: 1.26**.
Supplemental health insurance coverage;
Characteristic: None;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.26**;
Odds ration: Big problem seeing a specialist[B]: 1.91**;
Odds ration: Never scheduled an appointment promptly[C]: 1.60**.
Supplemental health insurance coverage;
Characteristic: Medicaid;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.27**;
Odds ration: Big problem seeing a specialist[B]: 1.64**;
Odds ration: Never scheduled an appointment promptly[C]: 1.33**.
Supplemental health insurance coverage;
Characteristic: Non-Medicaid;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Educational attainment;
Characteristic: No high school diploma;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.84**;
Odds ration: Big problem seeing a specialist[B]: 1.04;
Odds ration: Never scheduled an appointment promptly[C]: 1.03.
Educational Attainment;
Characteristic: High school diploma;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Educational Attainment;
Characteristic: 4-year college degree or more;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.25**;
Odds ration: Big problem seeing a specialist[B]: 1.20**;
Odds ration: Never scheduled an appointment promptly[C]: 1.15*.
Proxy assisted in survey completion;
Characteristic: Yes;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.02;
Odds ration: Big problem seeing a specialist[B]: 1.00;
Odds ration: Never scheduled an appointment promptly[C]: 0.89*.
Proxy assisted in survey completion;
Characteristic: No;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Urban or rural residence;
Characteristic: Urban;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.99;
Odds ration: Big problem seeing a specialist[B]: 0.91*;
Odds ration: Never scheduled an appointment promptly[C]: 1.03.
Urban or rural residence;
Characteristic: Rural;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Quartile of hospital beds per capita;
Characteristic: Lowest;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.09**;
Odds ration: Big problem seeing a specialist[B]: 0.98;
Odds ration: Never scheduled an appointment promptly[C]: 0.98.
Quartile of hospital beds per capita;
Characteristic: Second;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.03;
Odds ration: Big problem seeing a specialist[B]: 1.03;
Odds ration: Never scheduled an appointment promptly[C]: 1.06*.
Quartile of hospital beds per capita;
Characteristic: Third;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.96*;
Odds ration: Big problem seeing a specialist[B]: 0.99;
Odds ration: Never scheduled an appointment promptly[C]: 0.98.
Quartile of hospital beds per capita;
Characteristic: Highest;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Quartile of ambulatory surgical centers per Medicare beneficiary;
Characteristic: Lowest;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.94*;
Odds ration: Big problem seeing a specialist[B]: 0.93*;
Odds ration: Never scheduled an appointment promptly[C]: 0.95.
Quartile of ambulatory surgical centers per Medicare beneficiary;
Characteristic: Second;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.89**;
Odds ration: Big problem seeing a specialist[B]: 1.06*;
Odds ration: Never scheduled an appointment promptly[C]: 0.95.
Quartile of ambulatory surgical centers per Medicare beneficiary;
Characteristic: Third;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.07*;
Odds ration: Big problem seeing a specialist[B]: 1.01;
Odds ration: Never scheduled an appointment promptly[C]: 1.07*.
Quartile of ambulatory surgical centers per Medicare beneficiary;
Characteristic: Highest;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Quartile of primary care physicians per capita;
Characteristic: Lowest;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.98;
Odds ration: Big problem seeing a specialist[B]: 1.03;
Odds ration: Never scheduled an appointment promptly[C]: 1.04.
Quartile of primary care physicians per capita;
Characteristic: Second;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.97;
Odds ration: Big problem seeing a specialist[B]: 0.98;
Odds ration: Never scheduled an appointment promptly[C]: 0.99.
Quartile of primary care physicians per capita;
Characteristic: Third;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.01;
Odds ration: Big problem seeing a specialist[B]: 0.97;
Odds ration: Never scheduled an appointment promptly[C]: 0.97.
Quartile of primary care physicians per capita;
Characteristic: Highest;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Quartile of specialist physicians per capita;
Characteristic: Lowest;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.90*;
Odds ration: Big problem seeing a specialist[B]: 1.01;
Odds ration: Never scheduled an appointment promptly[C]: 0.99.
Quartile of specialist physicians per capita;
Characteristic: Second;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.04*;
Odds ration: Big problem seeing a specialist[B]: 1.00;
Odds ration: Never scheduled an appointment promptly[C]: 0.97.
Quartile of specialist physicians per capita;
Characteristic: Third;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.09**;
Odds ration: Big problem seeing a specialist[B]: 1.01;
Odds ration: Never scheduled an appointment promptly[C]: 0.99.
Quartile of specialist physicians per capita;
Characteristic: Highest;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Quartile of Medicare managed care penetration;
Characteristic: Lowest;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.89**;
Odds ration: Big problem seeing a specialist[B]: 0.88**;
Odds ration: Never scheduled an appointment promptly[C]: 0.96.
Quartile of Medicare managed care penetration;
Characteristic: Second;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.01;
Odds ration: Big problem seeing a specialist[B]: 0.96*;
Odds ration: Never scheduled an appointment promptly[C]: 0.94*.
Quartile of Medicare managed care penetration;
Characteristic: Third;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.05*;
Odds ration: Big problem seeing a specialist[B]: 1.08**;
Odds ration: Never scheduled an appointment promptly[C]: 0.99.
Quartile of Medicare managed care penetration;
Characteristic: Highest;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Quartile of Medicare beneficiaries per capita;
Characteristic: Lowest;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.11**;
Odds ration: Big problem seeing a specialist[B]: 1.11**;
Odds ration: Never scheduled an appointment promptly[C]: 1.05.
Quartile of Medicare beneficiaries per capita;
Characteristic: Second;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.98;
Odds ration: Big problem seeing a specialist[B]: 0.97;
Odds ration: Never scheduled an appointment promptly[C]: 0.95*.
Quartile of Medicare beneficiaries per capita;
Characteristic: Third;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.92**;
Odds ration: Big problem seeing a specialist[B]: 0.94*;
Odds ration: Never scheduled an appointment promptly[C]: 0.96.
Quartile of Medicare beneficiaries per capita;
Characteristic: Highest;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Quartile of per capita income;
Characteristic: Lowest;
Odds ration: Big problem finding a personal doctor or nurse[A]: 1.01;
Odds ration: Big problem seeing a specialist[B]: 1.00;
Odds ration: Never scheduled an appointment promptly[C]: 0.94.
Quartile of per capita income;
Characteristic: Second;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.99;
Odds ration: Big problem seeing a specialist[B]: 0.99;
Odds ration: Never scheduled an appointment promptly[C]: 0.98.
Quartile of per capita income;
Characteristic: Third;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.98;
Odds ration: Big problem seeing a specialist[B]: 1.01;
Odds ration: Never scheduled an appointment promptly[C]: 1.03.
Quartile of per capita income;
Characteristic: Highest;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Year;
Characteristic: 2000;
Odds ration: Big problem finding a personal doctor or nurse[A]:
1.00[D];
Odds ration: Big problem seeing a specialist[B]: 1.00[D];
Odds ration: Never scheduled an appointment promptly[C]: 1.00[D].
Year;
Characteristic: 2001;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.81**;
Odds ration: Big problem seeing a specialist[B]: 0.88*;
Odds ration: Never scheduled an appointment promptly[C]: 1.04.
Year;
Characteristic: 2002;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.88**;
Odds ration: Big problem seeing a specialist[B]: 1.00;
Odds ration: Never scheduled an appointment promptly[C]: 1.62**.
Year;
Characteristic: 2003;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.82**;
Odds ration: Big problem seeing a specialist[B]: 0.94;
Odds ration: Never scheduled an appointment promptly[C]: 1.43**.
Year;
Characteristic: 2004;
Odds ration: Big problem finding a personal doctor or nurse[A]: 0.74**;
Odds ration: Big problem seeing a specialist[B]: 0.82**;
Odds ration: Never scheduled an appointment promptly[C]: 1.46**.
Source: GAO analysis of CMS's Medicare CAHPS and ARF data.
Legend: **= significant at the 0.0001 level; *= significant at the 0.05
level.
Note: Bolded odds ratios indicate a value equal to or below 0.85, and
equal to or above 1.15. Nonbolded odds ratios indicate a value from
0.85 to 1.15.
[A] These results were derived from the responses of beneficiaries who
answered that they changed personal doctors since enrolling in
Medicare--an average of 47 percent a year.
[B] These results were derived from the responses of beneficiaries who
answered that they needed to see a specialist in the past 6 months--an
average of 56 percent a year.
[C] These results were derived from the responses of beneficiaries who
answered that they needed an appointment in the past 6 months--an
average of 74 percent a year.
[D] Omitted reference group.
[End of table]
Based on the results of our logistic regression analysis, we identified
beneficiary characteristics that were associated at the 0.05 level of
significance or better with either a substantial increased likelihood-
-an odds ratio greater than or equal to 1.15--or a substantial
decreased likelihood--an odds ratio less than or equal to 0.85--of
reporting a major difficulty.[Footnote 62] For these characteristics,
we computed a readily understandable measure--the percentage of
respondents in each group who reported having a major difficulty--for
each of the three survey questions.[Footnote 63] However, for one
characteristic--educational attainment of a 4-year college degree or
more--we had to use a more sophisticated technique to account for
confounding factors. We estimated the likelihood of a typical
beneficiary reporting major difficulty finding a personal doctor or
nurse.[Footnote 64],[Footnote 65] We then compared that likelihood to
the estimated likelihood for a beneficiary who had a 4-year college
degree and who was typical in all other respects.
In order to understand how reports of major difficulties accessing
physician services changed over time and varied among states, we
analyzed the proportion of beneficiaries reporting major difficulties
on each of the three questions related to physician access by state of
residence and by survey year. We also calculated these proportions for
each survey year by all urban and rural areas in the nation.
Data Reliability and Limitations:
We took several steps to ensure that the CAHPS data were sufficiently
reliable for our analysis. We examined the accuracy and completeness of
the data by testing for implausible values and internal
consistency.[Footnote 66] In addition, we interviewed experts at CMS
about whether the CAHPS data could appropriately be used as we
intended. We concluded that the data were sufficiently reliable for the
purpose of this analysis. We conducted our work from October 2004
through June 2006 in accordance with generally accepted government
auditing standards.
There were three main limitations to our analysis. First, the CAHPS
questions on finding a personal provider and scheduling an appointment
were not limited to physician services.[Footnote 67] (See table 8.) If
these survey questions had asked only about access to physician
services, we likely would have found different proportions of
beneficiaries who reported big problems finding a personal provider or
who reported never being able to schedule an appointment promptly.
Second, the proportions of beneficiaries reporting major difficulties
accessing physician services may not be representative of the national
population of Medicare beneficiaries.[Footnote 68] Finally, although we
endeavored to model all of the important beneficiary characteristics
using logistic regression, we lacked some information that may have
been important, such as beneficiary income.
[End of section]
Appendix II: Methods Used to Analyze Medicare Claims Data:
To analyze Medicare beneficiaries' access to physician services,
through their utilization of services, we used Medicare Part B claims
data from the National Claims History (NCH) files. We constructed data
sets for 100 percent of Medicare claims for physician services
performed by physicians in the first 28 days of April of 2000 through
2005.[Footnote 69] These data encompass several periods: 2 years in
which fee increases were greater than the increase in the estimated
cost of providing services (2000 and 2001), 1 year in which fees
decreased (2002), and 3 years in which fee increases were less than
inflation in the estimated cost of providing services (2003, 2004, and
2005). We established a consistent cutoff date (the last Friday in
September of the subsequent year) for each year's data file and only
included those claims for April services that had been submitted by
that date.[Footnote 70] Because claims continue to accrete in the data
files, this step was necessary to ensure that earlier years were not
more complete than later years. We supplemented these claims files with
CMS data on the number of beneficiaries in the FFS program as of March
of each year from the Medicare Managed Care Market Penetration
Quarterly State/County Data Files. In addition, on the basis of
beneficiary location, we associated each service with an urban or rural
location, using the Office of Management and Budget's classification of
metropolitan statistical areas (MSA).
We constructed several utilization measures to determine whether
Medicare beneficiaries experienced changes in their access to physician
services; these indicators included:
* the percentage of Medicare FFS beneficiaries obtaining services in
April of each year,[Footnote 71]
* the total number of physician services received, and:
* the total number of physician services per beneficiary who received
services.
We analyzed these utilization measures nationally, for urban and rural
areas within each state, and for specific services, such as office
visits for new and established patients. Using MSAs, we classified the
nation's counties as urban or rural, consolidated the urban counties
and rural counties in each state and the District of Columbia, and
created 99 geographic areas to analyze access at a subnational
level.[Footnote 72] We also determined the number of physicians billing
Medicare, whether services were performed by participating or
nonparticipating physicians, and whether claims for physician services
were paid either on assignment or not on assignment. We did not adjust
the data for factors that could affect the provision and use of
physician services, such as incidence of illness or coverage of new
benefits.
Data Reliability:
Medicare claims data, which are used by the Medicare program as a
record of payments made to health care providers, are closely monitored
by both CMS and the Medicare carriers--contractors that process,
review, and pay claims for Part B-covered services. The data are
subject to various internal controls, including checks and edits
performed by the carriers before claims are submitted to CMS for
payment approval. Although we did not review these internal controls,
we did assess the reliability of the NCH data. First, we reviewed all
existing information about the data, including the data dictionary and
file layouts. We also interviewed experts at CMS who regularly use the
data for evaluation and analysis. We examined the data files for
obvious errors, missing values, values outside of expected ranges, and
dates outside of expected time frames. We found the data to be
sufficiently reliable for the purposes of this report. We also assessed
the reliability of the Medicare Managed Care Market Penetration
Quarterly State/County Data Files by examining the data for obvious
errors, missing values, and values outside of expected ranges. In
addition, to further assess the reliability of these supplementary
data, we interviewed experts at CMS who are responsible for the
creation of these files and who regularly use the data for evaluation
and analysis. We found these data to be sufficiently reliable for the
purposes of this report.
[End of section]
Appendix III: Specific Physician Services Reviewed:
Using the Berenson-Eggers Type of Service (BETOS) code to which each
procedure code in our claims data was assigned, we reviewed specific
categories of physician services. According to the CMS, the BETOS
coding system consists of readily understood clinical categories, is
stable over time, and is relatively immune to minor changes in
technology or practice patterns. Table 11 shows the specific categories
we reviewed and the percentage change in the number of services
provided per 1,000 beneficiaries from April 2000 to April 2005. This
table highlights certain frequently performed services and procedures.
We collapsed data on other services and procedures into summary
categories.
Table 10: Percentage Change in the Number of Services Provided per
1,000 Medicare Beneficiaries, April 2000 to April 2005:
Overall service category: Evaluation and management (E&M);
Specific category: Office visits-new patients;
Services per 1,000 Medicare beneficiaries, April 2000: 26.3;
Services per 1,000 Medicare beneficiaries, April 2005: 27.6;
Percentage change, April 2000 to April 2005[A]: 5.0.
Overall service category: Evaluation and management (E&M);
Specific category: Office visits-established patients;
Services per 1,000 Medicare beneficiaries, April 2000: 404.8;
Services per 1,000 Medicare beneficiaries, April 2005: 454.4;
Percentage change, April 2000 to April 2005[A]: 12.2.
Overall service category: Evaluation and management (E&M);
Specific category: Hospital visits;
Services per 1,000 Medicare beneficiaries, April 2000: 170.6;
Services per 1,000 Medicare beneficiaries, April 2005: 209.9;
Percentage change, April 2000 to April 2005[A]: 23.0.
Overall service category: Evaluation and management (E&M);
Specific category: Emergency room visits;
Services per 1,000 Medicare beneficiaries, April 2000: 31.6;
Services per 1,000 Medicare beneficiaries, April 2005: 36.4;
Percentage change, April 2000 to April 2005[A]: 15.3.
Overall service category: Evaluation and management (E&M);
Specific category: Other E&M services;
Services per 1,000 Medicare beneficiaries, April 2000: 193.6;
Services per 1,000 Medicare beneficiaries, April 2005: 204.5;
Percentage change, April 2000 to April 2005[A]: 5.6.
Overall service category: Imaging;
Specific category: Advanced imaging- CAT scans;
Services per 1,000 Medicare beneficiaries, April 2000: 24.6;
Services per 1,000 Medicare beneficiaries, April 2005: 40.6;
Percentage change, April 2000 to April 2005[A]: 64.7.
Overall service category: Imaging;
Specific category: Advanced imaging-MRIs;
Services per 1,000 Medicare beneficiaries, April 2000: 6.5;
Services per 1,000 Medicare beneficiaries, April 2005: 12.7;
Percentage change, April 2000 to April 2005[A]: 93.5.
Overall service category: Imaging;
Specific category: Imaging procedures;
Services per 1,000 Medicare beneficiaries, April 2000: 15.8;
Services per 1,000 Medicare beneficiaries, April 2005: 22.7;
Percentage change, April 2000 to April 2005[A]: 43.7.
Overall service category: Imaging;
Specific category: Standard imaging;
Services per 1,000 Medicare beneficiaries, April 2000: 152.6;
Services per 1,000 Medicare beneficiaries, April 2005: 199.8;
Percentage change, April 2000 to April 2005[A]: 31.0.
Overall service category: Procedures: Major;
Specific category: Coronary artery bypass grafts;
Services per 1,000 Medicare beneficiaries, April 2000: 1.1;
Services per 1,000 Medicare beneficiaries, April 2005: 0.8;
Percentage change, April 2000 to April 2005[A]: -30.5.
Overall service category: Procedures: Major;
Specific category: Aneurysm repairs;
Services per 1,000 Medicare beneficiaries, April 2000: 0.1;
Services per 1,000 Medicare beneficiaries, April 2005: 0.2;
Percentage change, April 2000 to April 2005[A]: 65.3.
Overall service category: Procedures: Major;
Specific category: Thromboendarterectomies;
Services per 1,000 Medicare beneficiaries, April 2000: 0.3;
Services per 1,000 Medicare beneficiaries, April 2005: 0.2;
Percentage change, April 2000 to April 2005[A]: -23.7.
Overall service category: Procedures: Major;
Specific category: Coronary angioplasties;
Services per 1,000 Medicare beneficiaries, April 2000: 0.9;
Services per 1,000 Medicare beneficiaries, April 2005: 1.2;
Percentage change, April 2000 to April 2005[A]: 34.2.
Overall service category: Procedures: Major;
Specific category: Pacemaker insertions;
Services per 1,000 Medicare beneficiaries, April 2000: 0.6;
Services per 1,000 Medicare beneficiaries, April 2005: 1.0;
Percentage change, April 2000 to April 2005[A]: 63.9.
Overall service category: Procedures: Major;
Specific category: Other cardiac procedures;
Services per 1,000 Medicare beneficiaries, April 2000: 10.1;
Services per 1,000 Medicare beneficiaries, April 2005: 8.2;
Percentage change, April 2000 to April 2005[A]: -18.8.
Overall service category: Procedures: Major;
Specific category: Hip fracture repairs;
Services per 1,000 Medicare beneficiaries, April 2000: 0.5;
Services per 1,000 Medicare beneficiaries, April 2005: 0.4;
Percentage change, April 2000 to April 2005[A]: -12.8.
Overall service category: Procedures: Major;
Specific category: Hip replacements;
Services per 1,000 Medicare beneficiaries, April 2000: 0.3;
Services per 1,000 Medicare beneficiaries, April 2005: 0.4;
Percentage change, April 2000 to April 2005[A]: 11.1.
Overall service category: Procedures: Major;
Specific category: Knee replacements;
Services per 1,000 Medicare beneficiaries, April 2000: 0.5;
Services per 1,000 Medicare beneficiaries, April 2005: 0.7;
Percentage change, April 2000 to April 2005[A]: 47.1.
Overall service category: Procedures: Major;
Specific category: Other orthopedic procedures;
Services per 1,000 Medicare beneficiaries, April 2000: 1.6;
Services per 1,000 Medicare beneficiaries, April 2005: 2.2;
Percentage change, April 2000 to April 2005[A]: 35.5.
Overall service category: Procedures: Major;
Specific category: Other major procedures;
Services per 1,000 Medicare beneficiaries, April 2000: 7.2;
Services per 1,000 Medicare beneficiaries, April 2005: 7.2;
Percentage change, April 2000 to April 2005[A]: 0.1.
Overall service category: Procedures: Minor;
Specific category: Ambulatory procedures;
Services per 1,000 Medicare beneficiaries, April 2000: 29.9;
Services per 1,000 Medicare beneficiaries, April 2005: 50.4;
Percentage change, April 2000 to April 2005[A]: 68.6.
Overall service category: Procedures: Minor;
Specific category: Corneal transplants;
Services per 1,000 Medicare beneficiaries, April 2000: 0.0;
Services per 1,000 Medicare beneficiaries, April 2005: 0.0;
Percentage change, April 2000 to April 2005[A]: -17.3.
Overall service category: Procedures: Minor;
Specific category: Cataract removals/lens insertions;
Services per 1,000 Medicare beneficiaries, April 2000: 4.7;
Services per 1,000 Medicare beneficiaries, April 2005: 4.8;
Percentage change, April 2000 to April 2005[A]: 2.2.
Overall service category: Procedures: Minor;
Specific category: Retinal detachment repairs;
Services per 1,000 Medicare beneficiaries, April 2000: 0.1;
Services per 1,000 Medicare beneficiaries, April 2005: 0.1;
Percentage change, April 2000 to April 2005[A]: 8.9.
Overall service category: Procedures: Minor;
Specific category: Eye procedure treatments;
Services per 1,000 Medicare beneficiaries, April 2000: 0.8;
Services per 1,000 Medicare beneficiaries, April 2005: 0.9;
Percentage change, April 2000 to April 2005[A]: 14.0.
Overall service category: Procedures: Minor;
Specific category: Other eye procedures; Services per 1,000 Medicare
beneficiaries, April 2000: 3.2;
Services per 1,000 Medicare beneficiaries, April 2005: 4.5;
Percentage change, April 2000 to April 2005[A]: 39.3.
Overall service category: Procedures: Minor;
Specific category: Arthroscopies;
Services per 1,000 Medicare beneficiaries, April 2000: 0.5;
Services per 1,000 Medicare beneficiaries, April 2005: 0.8;
Percentage change, April 2000 to April 2005[A]: 65.1.
Overall service category: Procedures: Minor;
Specific category: Upper gastrointestinal endoscopies;
Services per 1,000 Medicare beneficiaries, April 2000: 4.3;
Services per 1,000 Medicare beneficiaries, April 2005: 5.2;
Percentage change, April 2000 to April 2005[A]: 20.6.
Overall service category: Procedures: Minor;
Specific category: Sigmoidoscopies;
Services per 1,000 Medicare beneficiaries, April 2000: 1.7;
Services per 1,000 Medicare beneficiaries, April 2005: 0.5;
Percentage change, April 2000 to April 2005[A]: -69.0.
Overall service category: Procedures: Minor;
Specific category: Colonoscopies;
Services per 1,000 Medicare beneficiaries, April 2000: 5.1;
Services per 1,000 Medicare beneficiaries, April 2005: 7.1;
Percentage change, April 2000 to April 2005[A]: 39.7.
Overall service category: Procedures: Minor;
Specific category: Cystoscopies;
Services per 1,000 Medicare beneficiaries, April 2000: 3.2;
Services per 1,000 Medicare beneficiaries, April 2005: 3.6;
Percentage change, April 2000 to April 2005[A]: 13.6.
Overall service category: Procedures: Minor;
Specific category: Bronchoscopies;
Services per 1,000 Medicare beneficiaries, April 2000: 0.7;
Services per 1,000 Medicare beneficiaries, April 2005: 1.0;
Percentage change, April 2000 to April 2005[A]: 56.3.
Overall service category: Procedures: Minor;
Specific category: Laryngoscopies;
Services per 1,000 Medicare beneficiaries, April 2000: 1.0;
Services per 1,000 Medicare beneficiaries, April 2005: 1.3;
Percentage change, April 2000 to April 2005[A]: 38.5.
Overall service category: Procedures: Minor;
Specific category: Other endoscopic procedures;
Services per 1,000 Medicare beneficiaries, April 2000: 1.4;
Services per 1,000 Medicare beneficiaries, April 2005: 1.7;
Percentage change, April 2000 to April 2005[A]: 18.1.
Overall service category: Procedures: Minor;
Specific category: Dialysis services;
Services per 1,000 Medicare beneficiaries, April 2000: 7.7;
Services per 1,000 Medicare beneficiaries, April 2005: 8.1;
Percentage change, April 2000 to April 2005[A]: 5.9.
Overall service category: Procedures: Minor;
Specific category: Other minor procedures;
Services per 1,000 Medicare beneficiaries, April 2000: 104.0;
Services per 1,000 Medicare beneficiaries, April 2005: 158.4;
Percentage change, April 2000 to April 2005[A]: 52.3.
Overall service category: Procedures: Minor;
Specific category: Anesthesia;
Services per 1,000 Medicare beneficiaries, April 2000: 14.5;
Services per 1,000 Medicare beneficiaries, April 2005: 16.6;
Percentage change, April 2000 to April 2005[A]: 14.3.
Overall service category: Tests;
Specific category: Lab tests;
Services per 1,000 Medicare beneficiaries, April 2000: 5.4;
Services per 1,000 Medicare beneficiaries, April 2005: 33.8;
Percentage change, April 2000 to April 2005[A]: 530.4.
Overall service category: Tests;
Specific category: Electrocardiograms;
Services per 1,000 Medicare beneficiaries, April 2000: 59.0;
Services per 1,000 Medicare beneficiaries, April 2005: 69.8;
Percentage change, April 2000 to April 2005[A]: Overall service
category: 18.3.
Overall service category: Tests;
Specific category: Stress tests;
Services per 1,000 Medicare beneficiaries, April 2000: 9.7;
Services per 1,000 Medicare beneficiaries, April 2005: 14.1;
Percentage change, April 2000 to April 2005[A]: 44.9.
Overall service category: Tests;
Specific category: EKG monitoring;
Services per 1,000 Medicare beneficiaries, April 2000: 2.7;
Services per 1,000 Medicare beneficiaries, April 2005: 3.3;
Percentage change, April 2000 to April 2005[A]: 23.7.
Overall service category: Tests;
Specific category: Other nonlab tests;
Services per 1,000 Medicare beneficiaries, April 2000: 26.9;
Services per 1,000 Medicare beneficiaries, April 2005: 39.0;
Percentage change, April 2000 to April 2005[A]: 44.7.
Overall service category: All services;
Specific category: [Empty];
Services per 1,000 Medicare beneficiaries, April 2000: 1,417.4;
Services per 1,000 Medicare beneficiaries, April 2005: 1,757.1;
Percentage change, April 2000 to April 2005[A]: 24.0.
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Note: Services were included if they were received in the first 28 days
of April.
[A] Percentage change was calculated prior to rounding.
[End of table]
[End of section]
Appendix IV: Comments from the Centers for Medicare & Medicaid
Services:
Department Of Health & Human Services:
Centers for Medicare & Medicaid Services:
200 Independence Avenue SW:
Washington, DC 20201:
Jun 26 2006:
To: A. Bruce Steinwald:
Director, Health Care:
Government Accountability Office:
From: Mark B. McClellan, M.D., Ph.D.
Administrator:
Centers for Medicare & Medicaid Services:
Subject: Government Accountability Office (GAO) Draft Report: "Medicare
Physician Services: Use of Services Increasing Nationwide and
Relatively Few Beneficiaries Report Major Access Problems" (GAO-06-
704):
Thank you for the opportunity to review and comment on the draft
report, "Medicare Physician Services: Use of Services Increasing
Nationwide and Relatively Few Beneficiaries Report Major Access
Problems," dated June 7, 2006 (the Draft Report). CMS is deeply
committed to ensuring continued beneficiary access to care as we move
toward the goal of paying for the right care for the right person at
the right time while simultaneously attempting to address the long-term
fiscal sustainability of the Medicare program. GAO findings reflect
similar results of surveys conducted in recent years by the Centers for
Medicare & Medicaid Services (CMS), including the annual Fee-for-
Service Consumer Assessment of Health Plans Study (FFS CAHPS) reports,
which have been completed for the years 2000 to 2004.
The CAHPS surveys which serve as the basis for the reports are part of
the first comprehensive effort to assess consumer experiences with
their health plans and services. The Medicare CAHPS effort consists of.
the Medicare (FFS) survey, a disenrollment survey, and a Medicare
Advantage survey. These surveys are part of a group of consumer surveys
developed by a consortium of researchers from the Research Triangle
Institute, the RAND Corporation, and the Harvard Medical School through
cooperative agreements with the Agency for Healthcare Research and
Quality. The goal of the CAHPS initiative, which began in 1995, was to
develop and test standardized questionnaires and report formats that
could be used to collect and report meaningful and reliable information
about health plans. The surveys contain core items that can be used
with any population and additional items targeted to particular groups.
Thus, they can be used with all types of health insurance consumers,
including Medicaid recipients, Medicare beneficiaries, those who are
commercially insured, and across the full range of health care delivery
systems. The core CAHPS survey asks respondents for four overall
ratings of. their doctor; specialist (if used); overall health care;
and health care plan. Information from most of the specific questions
is combined to create composite scores on getting needed care, getting
care quickly, doctor communication, courtesy and helpfulness of office
staff, and paperwork, information, and customer service.
In response to anecdotal reports that suggested beneficiaries in
certain parts of the country may be having difficulty finding
physicians who will accept Medicare patients, CMS designed and
implemented a monitoring system to track beneficiaries' access to
physicians' services as market dynamics change. The data from a variety
of sources, including claims, CAHPS surveys, beneficiary inquiries to
the 1-800-Medicare number, and environmental scanning activities, do
not suggest the presence of a national access to care problem. We have,
however, identified access problems in certain geographic areas, e.g.,
Alaska, Puerto Rico, that predate earlier cuts in physician payments.
To further investigate this issue, in 2003 CMS conducted a targeted
survey of Medicare beneficiaries on physician access issues in 11 local
markets. The study assessed the extent to which beneficiaries were
experiencing problems in accessing physicians' services and whether
certain types of beneficiaries were more likely to experience problems.
It also examined the reasons given by beneficiaries for reported
problems, with the goal of identifying whether there is evidence of a
link between changes in physician fees and access problems. Due to the
sampling method, the findings cannot be generalized beyond the study
area. However, the results suggest that these fee reductions have not
led to marked restrictions in access to care. Even though the study
targeted geographic areas thought most likely to be experiencing
difficulties, relatively few Medicare beneficiaries in these local
markets reported major problems with access to physician care, and only
a small percentage had problems attributed to physicians not taking new
Medicare patients or limiting Medicare participation. The findings also
indicate that access problems are more common among certain subgroups
in these markets that may be especially vulnerable to changes in
access, including beneficiaries who had recently moved to the area or
who had changed insurance coverage. Finally, while only a small
percentage of respondents reported access is worse than in the past,
more said it is getting worse than say it is getting better.
It is in this context that CMS turns to the findings of GAO's Draft
Report. The Draft Report focused upon: 1) trends and patterns in
beneficiaries' perceptions of the availability of physicians' services
from 2000 to 2004; 2) trends in beneficiaries' utilization of
physicians' services from 2000 to 2005; and 3) indicators of physician
supply and willingness to serve Medicare beneficiaries from 2000 to
2005. The Draft Report concludes that beneficiaries were able to access
physicians' services. In fact, the Draft Report found that both the
utilization and complexity of services had increased over this period.
GAO did not attempt to assess the medical appropriateness of the
increases. Furthermore, GAO concludes that the implications of these
trends in utilization for the long-term fiscal sustainability of the
Medicare program would require careful examination.
Overall, CMS finds that the Draft Report clearly describes a well-
conceived and executed analysis of existing data relevant to the
concerns and questions surrounding the impact of Medicare's efforts to
control spending on physicians' services on beneficiaries' access to
those services. The results, insofar as they use similar data, are
comparable to existing CMS research and monitoring results. CMS has no
concerns regarding the conclusions stated in the Draft Report as they
seem warranted and sustained by the data and analyses presented.
The main conclusion of the Draft Report (i.e., that ".Relatively Few
Beneficiaries Report Major Access Problems") seems to conform with
presentations of similar findings in the annual CAHPS reports. Because
the GAO Draft Report employed data only from the 50 continental United
States and the District of Columbia but excluded any FFS CAHPS
information from Puerto Rico or the US Virgin Islands, it is not
possible to make exact comparisons with the published CMS Medicare FFS
CAHPS Reports.
The CMS noted a number of minor editorial and technical points that do
not substantively change the GAO analyses or materially change the
results and conclusions presented in the Draft Report, but may prove
helpful in final editing as well as future analyses. These points are:
1. Future analyses might include claims reflecting services from
Federally Qualified Health Centers (FQHC) and Rural Health Clinics
(RHC) not found in Part B claims but are found within the Outpatient
file;
2. The Report should strengthen its description of the information that
is being presented as taken from the Medicare FFS CAHPS® Survey;
3. Footnote 66 on page 47 is in effort because laboratories would not
be included among "physicians or other health providers" with respect
to beneficiary access in the cited CAHPS item;
4. The Report uses the term "physician services" which is inconsistent
with the term "physicians' services" used in the legislation requiring
the study that forms the basis of the Draft Report, namely Section 604
of the Medicare Prescription Drug, Improvement and Modernization Act of
2003 (P.L. 108-173).
These points are discussed below.
Due to the generally high quality of the GAO Draft Report, CMS does not
feel it is necessary to address the Draft Report item-by-item. Instead,
we will address the few technical and editorial issues directly by
describing them and offering specific suggestions for editing the Draft
Report with respect to each issue.
1) Future analyses might include claims reflecting services from
Federally Qualified Health Centers (FQHC) and Rural Health Clinics
(RHC) not found in Part B claims but are found within the Outpatient
file.
The analysis of utilization trends used CMS Part B claims only as
described briefly on page 3 and in detail in Appendix II (page 48-50)
of the Draft Report. Relying solely upon Part B claims from the
National Historical Claims under-represents utilization of Medicare
beneficiaries because it omits the services provided by FQHC and RHC.
Due to the nature of FQHC and RHC reimbursement, those claims are
submitted on a form UB-92 and included in the outpatient file
representing facility services, not the physicians' services Part B
file. Given that FQHC and RHC are most often located in health
professional shortage areas and medically underserved areas, the
absence of those claims would tend to undercount ambulatory services
obtained by Medicare beneficiaries, especially those residing in rural
areas and among underserved populations. An undercount of beneficiary
services would not likely affect the Draft Report's general conclusion
that access to physicians' services stayed the same or improved (as
stated on page 37). Adding these FQHC and RHC claims to the GAO
analyses might affect the results of several sub-analyses, namely
geographic variations in utilization patterns (pp 25-31). Additional
services in underserved areas may reduce the observed geographic
variation (e.g., the proportion of beneficiaries receiving services in
Alaska and other rural regions). It may also affect the relative
strength of the impact of non-white status on utilization. CMS does not
believe the omission of these claims in the reported analyses is a
concern because the change by adding utilization in the rural areas and
among the underserved populations would likely strengthen support for
the conclusion that beneficiary utilization increased from 2000 to
2005.
The Draft Report might include a statement in footnote 11 on page 3,
and again in footnote 68 on page 48, indicating that the definition of
physicians' services did not include those physicians' services billed
through an FQHC or RHC.
2) The Report should strengthen its description of the information that
is being presented as taken from the Medicare FFS CAHPS Survey.
Although this would not change the findings of the Draft Report, in the
interests of clarity for readers the GAO should strengthen its
description of the information that is being presented as being from
the Medicare FFS CAHPS Survey, and note that there is another Medicare
CAHPS Survey, namely the Medicare Advantage (MA) CAHPS Survey, for
which no measures appear to be presented in the Draft Report. This
distinction perhaps can be made as an additional footnote on page 2 of
the Draft Report, following footnote 5. The additional footnote should
state something to the effect that "CMS has also collected beneficiary
experience information on an annual basis from those beneficiaries
enrolled in Medicare Advantage health plans in the Medicare Advantage
CAHPS Survey. The measures of beneficiary access to physicians in MA
health plans are not presented in this report."
We would further recommend that each time the Medicare FFS CAHPS
measures are presented in the GAO Draft Report that they be labeled as
such (i.e., as "Medicare FFS CAHPS") and not simply as Medicare CAHPS
measures. The omission of the "FFS" distinction in each case where the
FFS CAHPS measures are presented could cause confusion to the reader
who does not realize that the information being presented does not
include any beneficiary experience information from those beneficiaries
who were enrolled in a Medicare Advantage plan, which the GAO Draft
Report correctly points out on page 6 was about 13 percent of the total
Medicare population in 2005 (i.e., 100 - 87 percent shown on page 6).
Places in the Draft Report where the Medicare CAHPS® information should
be labeled as Medicare FFS CAHPS occurs on at least the following
pages: 2, 3, 4, 12, 14, 20, 21, 22, 23, 30, and 31, as well as in the
discussion of the Medicare CAHPS Survey in the appendix on pages 41-
47.
3) Footnote 66 on page 47 is in error because laboratories would not be
included among 'physicians or other health providers" with respect to
beneficiary access in the cited CAHPS item.
Footnote 66 on page 47 erroneously states that "laboratories" might be
included in the Medicare CAHPS response categories concerning
beneficiary access to physicians or other health providers. This is not
the case. The response categories in the questions referred to in this
discussion include physicians, nurses (originally described as "nurse
practitioner" although the term "practitioner" was dropped in 2003),
and physician assistants.
We fully agree with the statements in discussion of the CAHPS
methodology on pages 46-47 that the Medicare FFS "CAHPS data were
sufficiently reliable for [the] analysis [performed] and that they
could appropriately be used as we intended." The last paragraph on page
47, however, should be modified given the issue of the error included
in Footnote 66 as noted above. While it is true that the survey
questions asked about access to both physicians and specific non-
physician practitioners, namely the categorical providers in the
responses listed (nurse or physician assistant), only about 2-3 percent
of all respondents noted these specific non-physician practitioners as
their personal health provider. The intent of the questions discussed
in this paragraph, and elsewhere in the Draft Report, was to obtain
information about access to a physician or to one of the other non-
physician practitioners specifically listed in the response categories.
In these situations, it is likely that the physician assistant and
probably many of the nurses were providing services in which they could
consult with a physician on an "as needed" basis. This is especially
the case with physician assistants, although in some States nurse
practitioners may practice independent of a physician.
4) The Report uses the term "physician services " which is inconsistent
with the term "physicians' services" used in the legislation requiring
the study underlying the Draft Report, namely section 604 of the
Medicare Prescription Drug, Improvement and Modernization Act of 2003
(MMA) (P. L. 108-173).
Finally, we note that the title of the Draft Report includes language
inconsistent with the statutory mandate which requires a study of
access of Medicare beneficiaries to "physicians' services." The body of
the report also contains this inconsistency. Section 604 of the MMA
(P.L. 108-173) requires GAO to conduct a study on access of Medicare
beneficiaries to "physicians' services." We suggest that the reference
to "physicians' services" in the report should be consistent with the
Medicare statute.
The CMS appreciates the opportunity to review the GAO Draft Report, GAO-
06-704 "Medicare Physician Services: Use of Services Increasing
Nationwide and Relatively Few Beneficiaries Report Major Access
Problems." CMS concurs with the major findings and conclusions
presented within this draft report. We believe the overall analytic
strategy for assessing Medicare physicians' services to be realistic
given the data sources available. We find the analyses to be sound, the
results comparable to similar CMS research results, and the conclusions
to be justified and appropriate in scope. We hope that the technical
and editorial issues addressed in this response strengthen and improve
the final published report. This GAO Draft Report on Medicare
physicians' services provides an independent confirmation of our
internal assessments of the current state of beneficiary access
problems for physicians' services. It also provides a solid basis for
continued monitoring of access to care and identifies two other major
factors (appropriateness of care and the cost of care) that must be
managed to maintain or improve the Medicare program.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
A. Bruce Steinwald (202) 512-7101 or steinwalda@gao.gov:
Acknowledgments:
James Cosgrove, Assistant Director; Kevin Dietz; Jessica Farb; Hannah
Fein; Zachary Gaumer; Rich Lipinski; Jennifer M. Rellick; Dan Ries; and
Eric Wedum made key contributions to this report.
FOOTNOTES
[1] For example, in February 2002, shortly after the fee reduction went
into effect, two congressional hearings on Medicare physician payments
were held. See Medicare Payment Policy: Ensuring Stability and Access
Through Physician Payments, Hearing Before the Subcommittee on Health
of the Committee on Energy and Commerce, House of Representatives,
February 14, 2002, Serial No. 107-91, Washington, D.C., and Physician
Payments, Hearing Before the Subcommittee on Health of the Committee on
Ways and Means, House of Representatives, February 28, 2002, Serial No.
107-70, Washington, D.C.
[2] The change in the cost of providing physician services is measured
by the Medicare Economic Index (MEI). MEI measures input prices for
resources needed to provide physician services. It is designed to
estimate the increase in the total cost for the average physician to
operate a medical practice.
[3] The Boards of Trustees of the Federal Hospital Insurance and
Federal Supplementary Medical Insurance Trust Funds, 2006 Annual Report
of the Boards of Trustees of the Federal Hospital Insurance and Federal
Supplementary Medical Insurance Trust Funds (Washington, D.C.: May 1,
2006).
[4] GAO, Medicare Fee-for-Service Beneficiary Access to Physician
Services: Trends in Utilization of Services, 2000 to 2002, GAO-05-145R
(Washington, D.C.: Jan. 12, 2005).
[5] Pub. L. No. 108-173, § 604, 117 Stat. 2066, 2301-02.
[6] CAHPS is a registered trademark of the Department of Health and
Human Services' Agency for Healthcare Research and Quality. CAHPS
refers to a family of surveys that asks consumers and patients to
evaluate their health care using a standardized set of questions. CMS
conducts a CAHPS survey of both the Medicare FFS population and the
Medicare Advantage population. Throughout this report we refer to the
FFS CAHPS ® survey as the CAHPS survey. Beginning in 2005, the CAHPS
acronym stands for Consumer Assessment of Healthcare Providers and
Systems.
[7] Between 100,000 and 125,000 individuals responded to the survey
each year.
[8] Throughout this report, we describe beneficiaries' collective
responses to the CAHPS survey questions as their perceptions of access.
[9] Throughout this report, we collectively characterize the most
negative responses to these three questions as "having major
difficulties."
[10] Our pattern of results would have been similar if we had analyzed
the three questions for reports of any problem, that is, a "small
problem" or "big problem" and "sometimes" or "never."
[11] We examined over 60 million claims for April of each year. These
claims samples from the month of April represent an annual snapshot of
beneficiary access to physician services for each of the 6 years.
Physician fee updates generally occur at the beginning of each calendar
year and remain constant throughout the year. We selected April to
allow time for the annual fee updates to be implemented and for
physician behavior to adjust to the new fees. To avoid "calendar bias"-
-that is, the occurrence of more weekdays in April in one year compared
to another--and to create an equal number of weekdays in each year's
data set, we limited each year's claims to services performed within
the first 28 days of the month.
[12] We 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.
[13] We excluded beneficiaries in Guam, Puerto Rico, and the U.S.
Virgin Islands because access issues in these areas may be
substantively different than those in the rest of the United States.
[14] In 2005, 42.5 million people were covered by Medicare: 35.8
million were age 65 and older, and 6.7 million were disabled.
[15] In 2005, about 93 percent of the 43 million individuals covered by
Medicare were enrolled in Part B.
[16] Medicare spending in 2005 was 2.7 percent of the gross domestic
product (GDP) and is projected to grow to 7.5 percent of GDP by 2035
and 12.9 percent of GDP by 2075.
[17] 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; E.S. Fisher, et al., "The Implications of Regional Variations
in Medicare Spending. Part 1: The Content, Quality, and Accessibility
of Care," Annals of Internal Medicine, vol. 138, no. 4 (2003): 273-287;
E.S. Fisher, et al., "The Implications of Regional Variations in
Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,"
Annals of Internal Medicine, vol. 138, no. 4 (2003): 288-298; and
Joseph P. Newhouse, Free for All? Lessons from the RAND Health
Insurance Experiment (Cambridge, Mass.: Harvard University Press,
1993).
[18] The first system of spending targets, the Medicare volume
performance standard (MVPS), was established along with the fee
schedule in 1992. In 1998, the sustainable growth rate (SGR) system
replaced MVPS. SGR is the current spending target system.
[19] Some services paid under the physician fee schedule do not have
RVUs associated with them; these services are priced by Medicare's
claims administration contractors.
[20] Medicare adjusts a service's RVU-based payment for area
differences in physicians' cost of operating a private medical
practice. The adjustment is made using geographic practice cost
indexes.
[21] In 2005, the RVUs for a midlevel office visit were 1.39 for
services provided in a non-facility setting and 0.94 for services
provided in a facility setting.
[22] Although beneficiaries are responsible for this amount, most
Medicare FFS beneficiaries--about 90 percent in 2002--have
supplementary coverage that covers out-of-pocket expenses, including
the beneficiary's coinsurance amount.
[23] Physicians may "opt out" of the Medicare program altogether and
charge any amount for the services they provide but they must inform
the beneficiary in advance of this arrangement. Under this option,
physicians must agree not to file any Medicare claims for 2 years, and
their patients are responsible for 100 percent of the charges.
Relatively few physicians--approximately 5,000 as of 2005--have opted
out of the Medicare program.
[24] The limiting charge is 115 percent of 95 percent of the Medicare
approved amount, or 109.25 percent.
[25] See Medicare Payment Advisory Commission, Report to the Congress,
Medicare Payment Policy (Washington, D.C.: March 2006).
[26] In 2005, 12 percent of Medicare beneficiaries had a small problem
and 13 percent had a big problem finding a new primary care physician.
Similarly, 16 percent of privately insured individuals had a small
problem and 9 percent had a big problem finding a new primary care
physician.
[27] In 2005, with regard to getting an appointment for routine care,
21 percent of Medicare beneficiaries sometimes experienced an unwanted
delay, 3 percent usually experienced an unwanted delay, and 2 percent
always experienced an unwanted delay. Similarly, among privately
insured individuals, 25 percent sometimes, 5 percent usually, and 3
percent always experienced an unwanted delay in getting an appointment
for routine care.
[28] See Medicare Payment Advisory Commission, Report to the Congress,
Medicare Payment Policy (Washington, D.C.: March 2005); Report to the
Congress, Medicare Payment Policy (Washington, D.C.: March 2004);
Report to the Congress, Medicare Payment Policy (Washington, D.C.:
March 2002); and Report to the Congress, Medicare Payment Policy
(Washington, D.C.: March 2000).
[29] Centers for Medicare & Medicaid Services and Mathematica Policy
Research, Inc., Results from the 2003 and 2004 Targeted Beneficiary
Surveys on Access to Physician Services Among Medicare Beneficiaries
(Washington, D.C.: Jan. 20, 2005).
[30] The 11 markets included the state of Alaska; Phoenix, Arizona; San
Diego, California; San Francisco, California; Denver, Colorado; Tampa,
Florida; Springfield, Missouri; Las Vegas, Nevada; Brooklyn, New York;
Fort Worth, Texas; and Seattle, Washington.
[31] Center for Studying Health System Change, Tracking Report:
Physician Acceptance of New Medicare Patients Stabilizes in 2004-2005
(Washington, D.C.: January 2006).
[32] The HSC Community Tracking Study Physician Survey is a nationally
representative telephone survey of physicians involved in direct
patient care in the continental United States. The survey had three
data collection periods, 1996-1997, 2000-2001, and 2004-2005.
[33] If the proportion of physicians who accepted "some" or "most" new
patients had been included, the percentage would have been higher.
[34] In each survey year, an average of 47 percent of beneficiaries
reported that they did not have the same personal doctor or nurse as
before joining Medicare.
[35] In each survey year, an average of 56 percent of beneficiaries
reported needing to see a specialist in the past 6 months.
[36] In each survey year, an average of 74 percent of beneficiaries
reported needing to schedule an appointment in the past 6 months.
[37] The proportion of beneficiaries who reported a big problem finding
a personal doctor or nurse increased from 2000 to 2004 in the District
of Columbia and Idaho.
[38] The proportion of beneficiaries who reported never being able to
schedule an appointment promptly increased from 2000 to 2004 in Alaska,
the District of Columbia, Idaho, and Nevada.
[39] Other beneficiary and area characteristics, such as sex, county of
residence, and county-level supply of physicians and hospital beds, did
not affect the proportion of beneficiaries reporting major
difficulties. (See app. I.)
[40] Beneficiaries' health status was self-reported.
[41] Fair or poor health status was associated with reporting major
access difficulties even after we controlled for other characteristics,
such as age and race. (See app. I.) In total, we controlled for survey
year and 15 beneficiary and area characteristics.
[42] Some beneficiaries under age 65 qualify for Medicare for other
reasons, such as having end-stage renal disease.
[43] When we controlled for the effect of other characteristics,
including self-reported health status, being under age 65 was
associated with reporting major access difficulties. (See app. I.)
Regardless of health status, these disabled beneficiaries reported
major difficulties more frequently. In total, we controlled for survey
year and 15 beneficiary and area characteristics.
[44] After we controlled for other beneficiary characteristics,
nonwhite race remained associated with reporting major access
difficulties for the questions on finding a specialist and scheduling
an appointment. (See app. I.) For the question on finding a personal
doctor or nurse, however, blacks were less likely to report a big
problem than whites, and Hispanics were as likely as whites to report a
big problem after we controlled for other beneficiary characteristics.
[45] After we controlled for other beneficiary characteristics, lack of
supplemental coverage from a source other than Medicaid remained
associated with reporting major difficulties accessing physician
services. (See app. I.)
[46] In total we controlled for survey year and 15 beneficiary and area
characteristics, which we describe in app. I.
[47] A typical beneficiary also had fair or poor self-reported health
status, had supplemental health insurance coverage only from a source
other than Medicaid, and resided in an urban area. See app. I for a
complete list of the typical characteristics--both beneficiary and area
related.
[48] Using 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.
[49] Per capita refers to the average number of services per 1,000
Medicare beneficiaries.
[50] Office visits can be provided by both primary care physicians and
specialists. We examined office visits because they are the typical
entry point into the health care system and the most basic level of
physician services.
[51] We examined office visits separately for new and established
patients to assess access to care trends among new patients who might
be more likely to experience access difficulties.
[52] The procedures included were coronary artery bypass grafts,
thromboendarterectomy, sigmoidoscopy, hip fracture repair, and corneal
transplant.
[53] Because the majority of physicians serving FFS Medicare
beneficiaries also likely serve beneficiaries in Medicare managed care,
we report the change in the total number of Medicare beneficiaries--FFS
and managed care combined. The number of FFS beneficiaries increased by
13 percent, an increase driven in part by a decline of about 18 percent
in the number of enrollees in managed care, from 6.8 million to 5.6
million.
[54] Physicians may decide on an annual basis whether they will be
Medicare participating physicians.
[55] We excluded responses from beneficiaries residing outside the 50
states and the District of Columbia in our analysis.
[56] About 50 percent of beneficiaries indicated a need for a new
personal provider. Similarly, about 60 percent self-reported a need for
access to specialists, and about 70 percent indicated that they needed
an appointment.
[57] When we conducted the analyses described in this appendix using
any negative responses--that is, both "big problem" and "small problem"
and both "never" and "sometimes"--the proportions were larger, but the
effects of beneficiary and area characteristics on the likelihood of
reporting a problem were about the same.
[58] Additionally, we tested whether the use of a proxy to help
respondents complete the survey had an effect on beneficiaries'
perceptions of access.
[59] The ARF, which is maintained by the Health Resources and Services
Administration, is a county-based health resources information database
that contains data from many sources, including the U.S. Census Bureau
and the American Medical Association. The ARF is a standard data source
that is well-documented and widely used. We linked year 2000 ARF data
to beneficiaries from all 5 CAHPS survey years for two reasons. First,
we reasoned that local area characteristics would not change much over
the CAHPS survey years--2000 through 2004. Second, some fields of ARF
data were not available for 2001 through 2004.
[60] In the year 2000, CAHPS data on county of residence were missing
for all beneficiaries living in eight states--Alaska, Idaho, Montana,
North Dakota, Rhode Island, South Dakota, Wyoming, and Vermont--and the
District of Columbia. These missing data rendered 3,600 beneficiaries-
-roughly 3 percent of the year 2000 CAHPS respondents--not linkable to
the ARF data.
[61] Time trends in the likelihood of reporting a major difficulty were
captured by including a variable for survey year in the model.
[62] We required the characteristic to be important in the same
direction--that is, an increased or a decreased likelihood--on at least
two of the three questions related to physician access.
[63] For illustrative purposes, we combined black, Hispanic, and other
race into one nonwhite category, when calculating the proportions for
race, and we combined all beneficiaries over age 65 into one age group
when calculating proportions for age.
[64] The characteristics of a typical beneficiary were female, white,
age 70-74, fair or poor health, no proxy assistance for completion of
the survey, high school diploma or some college, residence in an urban
area, and non-Medicaid supplemental health insurance coverage. We
assigned the study year 2003 and the second quartile of other measures,
such as primary care physicians per capita, as beneficiary
characteristics.
[65] For this characteristic, we chose to report the likelihood of
reporting major difficulties finding a personal doctor or nurse for
illustrative purposes; we also analyzed the likelihood of reporting
major difficulties seeing a specialist or making an appointment
promptly with somewhat similar results.
[66] In order to ensure the consistency of individuals' responses to
both the prior question on the need for care and the related access
question, we recoded some survey responses. For example, if an
individual answered in a prior question that he or she did not need a
specialist, we recoded the response on the access question related to
specialists to "not applicable." We also excluded observations with
implausible ARF values--less than 1 percent of all observations--where
complete ARF data were essential to the analysis.
[67] For example, the question on finding a personal provider may
include services provided by nonphysicians, such as personal nurses.
The question on scheduling an appointment promptly for health care may
include services other than those provided by physicians.
[68] While the CAHPS is a random sample, we subset the data such that
it became a nonprobability sample. A nonprobability sample's statistics
cannot be generalized to a population because some elements of the
population being studied have no chance or an unknown chance of being
selected as part of the sample.
[69] We excluded claims for services provided by nurse practitioners,
physician assistants, and other nonphysician practitioners. We included
services covered by the fee schedule as well as anesthesia services. We
identified claims for physician services covered by the fee schedule by
limiting the files to include only Healthcare Common Procedure Codes
that are on the physician fee schedule and covered by Medicare. We
excluded claims from beneficiaries in Guam, Puerto Rico, and the U.S.
Virgin Islands because access issues in these areas may be
substantively different than those in the rest of the United States.
[70] We chose the month of September so our data would include two
quarters of processed claims from April of each year. This equates to
about 95 percent of the claims for services provided in April of each
year.
[71] Beneficiaries refers to all FFS Medicare beneficiaries, not just
those for whom claims were filed.
[72] Rhode Island and New Jersey had no rural counties. The District of
Columbia is only counted as an urban area.
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