Medicare Physician Services
Utilization Trends Indicate Sustained Beneficiary Access with High and Growing Levels of Service in Some Areas of the Nation Gao ID: GAO-09-559 August 28, 2009Congress, policy analysts, and groups representing physicians have raised questions about beneficiary access to Medicare physician services. At the same time, high levels of spending for health care in some parts of the country, and rapid increases in spending for physician services, have been identified as factors that threaten the long-term fiscal sustainability of the Medicare program. GAO was asked to assess beneficiary access to physician services and to identify indicators of potential overutilization of physician services. In this report, GAO (1) examines whether, from 2000 through 2008, beneficiaries had problems accessing physician services; (2) identifies areas of the country in which Medicare beneficiaries are potentially overserved by physicians; and (3) describes characteristics that distinguish the potentially overserved areas from other areas in the nation. GAO analyzed the most recent data available from several sources, including an annual Centers for Medicare & Medicaid Services (CMS) survey of fee-for-service (FFS) Medicare beneficiaries, Medicare physician claims for services provided in April of each year from 2000 through 2008, the Health Resources and Services Administration's Area Resource File, and the U.S. Census Bureau.
GAO found that Medicare beneficiaries experienced few problems accessing physician services during its period of study. Very small percentages of Medicare beneficiaries--less than 3 percent--reported major difficulties accessing physician services in 2007 and 2008. The proportion of beneficiaries who received physician services and the number of services per beneficiary served increased nationwide from April 2000 to April 2008. Indicators of physician willingness to serve Medicare beneficiaries and to accept Medicare fees as payments in full also rose from 2000 to 2008. Potentially overserved areas--areas that were in the top half in both the level and growth in utilization of physician services--tend to be in the more densely populated urban regions and the eastern part of the United States. Large metropolitan areas were much more likely to be potentially overserved than rural and small metropolitan areas. Areas east of the Mississippi River were also more likely to be potentially overserved than those in the west. Potentially overserved and other areas are similar in demographic characteristics and the capacity to provide health care services. The two groups are also similar in Medicare beneficiary satisfaction with health care. In contrast, certain types of physician services, such as advanced imaging and minor procedures, are performed more frequently in potentially overserved areas relative to other areas, suggesting differences in physician practice patterns. In commenting on a draft of this report, CMS noted the agency's longstanding practice of monitoring the effect of policy changes on beneficiary access to Medicare services, and stated that this report would help in that effort.
GAO-09-559, Medicare Physician Services: Utilization Trends Indicate Sustained Beneficiary Access with High and Growing Levels of Service in Some Areas of the Nation
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Report to the Committee on Finance, U.S. Senate:
United States Government Accountability Office:
GAO:
August 2009:
Medicare Physician Services:
Utilization Trends Indicate Sustained Beneficiary Access with High and
Growing Levels of Service in Some Areas of the Nation:
GAO-09-559:
GAO Highlights:
Highlights of GAO-09-559, a report to the Committee on Finance, U.S.
Senate.
Why GAO Did This Study:
Congress, policy analysts, and groups representing physicians have
raised questions about beneficiary access to Medicare physician
services. At the same time, high levels of spending for health care in
some parts of the country, and rapid increases in spending for
physician services, have been identified as factors that threaten the
long-term fiscal sustainability of the Medicare program.
GAO was asked to assess beneficiary access to physician services and to
identify indicators of potential overutilization of physician services.
In this report, GAO (1) examines whether, from 2000 through 2008,
beneficiaries had problems accessing physician services; (2) identifies
areas of the country in which Medicare beneficiaries are potentially
overserved by physicians; and (3) describes characteristics that
distinguish the potentially overserved areas from other areas in the
nation.
GAO analyzed the most recent data available from several sources,
including an annual Centers for Medicare & Medicaid Services (CMS)
survey of fee-for-service (FFS) Medicare beneficiaries, Medicare
physician claims for services provided in April of each year from 2000
through 2008, the Health Resources and Services Administration‘s Area
Resource File, and the U.S. Census Bureau.
What GAO Found:
GAO found that Medicare beneficiaries experienced few problems
accessing physician services during its period of study. Very small
percentages of Medicare beneficiaries”less than 3 percent”reported
major difficulties accessing physician services in 2007 and 2008. The
proportion of beneficiaries who received physician services and the
number of services per beneficiary served increased nationwide from
April 2000 to April 2008. (See figure.) Indicators of physician
willingness to serve Medicare beneficiaries and to accept Medicare fees
as payments in full also rose from 2000 to 2008.
Potentially overserved areas”areas that were in the top half in both
the level and growth in utilization of physician services”tend to be in
the more densely populated urban regions and the eastern part of the
United States. Large metropolitan areas were much more likely to be
potentially overserved than rural and small metropolitan areas. Areas
east of the Mississippi River were also more likely to be potentially
overserved than those in the west.
Potentially overserved and other areas are similar in demographic
characteristics and the capacity to provide health care services. The
two groups are also similar in Medicare beneficiary satisfaction with
health care. In contrast, certain types of physician services, such as
advanced imaging and minor procedures, are performed more frequently in
potentially overserved areas relative to other areas, suggesting
differences in physician practice patterns.
In commenting on a draft of this report, CMS noted the agency‘s
longstanding practice of monitoring the effect of policy changes on
beneficiary access to Medicare services, and stated that this report
would help in that effort.
Figure: Trends in Utilization of Physician Services:
[Refer to PDF for image: two vertical bar graphs]
Percentage of Medicare FFS beneficiaries receiving physician services
in April, 2000-2008:
Year: 2000: 45.5%;
Year: 2001: 46.6%;
Year: 2002: 47.7%;
Year: 2003: 46.6%;
Year: 2004: 47.7%;
Year: 2005: 49.1%;
Year: 2006: 49.2%;
Year: 2007: 49.5%;
Year: 2008: 49.7%.
Number of physician services provided per 1,000 Medicare FFS
beneficiaries served in April, 2000-2008:
Year: 2000: 3,430;
Year: 2001: 3,535;
Year: 2002: 3,630;
Year: 2003: 3,669;
Year: 2004: 3,711;
Year: 2005: 3,851;
Year: 2006: 3,905;
Year: 2007: 3,943;
Year: 2008: 3,944.
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
[End of figure]
View GAO-09-559 or key components. For more information, contact A.
Bruce Steinwald at (202) 512-7114 or steinwalda@gao.gov.
[End of section]
Contents:
Letter:
Background:
Indicators Show Few Problems in Beneficiary Access to Physician
Services:
Potentially Overserved Areas Tend to Be in More Densely Populated Urban
Regions and the Eastern Part of the Country:
Potentially Overserved Areas Are Largely Similar to Other Areas, with
the Exception of Physician Practice Patterns:
Concluding Observations:
Agency and Industry Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Average Utilization Values by Geographic Area Type:
Appendix III: Utilization Status of Geographic Areas:
Appendix IV: Selected Physician Services in Potentially Overserved and
Other Areas:
Appendix V: Utilization Status of Medicare Physician Payment
Localities:
Appendix VI: Selected Physician Services in Potentially Overserved and
Other Medicare Physician Payment Localities:
Appendix VII: Utilization Status of Hospital Referral Regions:
Appendix VIII: Selected Physician Services in Potentially Overserved
and Other HRRs:
Appendix IX: Comments from the Centers for Medicare & Medicaid
Services:
Appendix X: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Medicare Beneficiaries Who Reported Major Difficulties
Accessing Physician Services, 2007-2008:
Table 2: Distribution of Utilization Status by Type of Geographic Area:
Table 3: Selected Demographic Characteristics in Potentially Overserved
and Other Areas:
Table 4: Selected Health Care Capacity Characteristics in Potentially
Overserved and Other Areas:
Table 5: Selected Medicare Beneficiary Satisfaction Indicators in
Potentially Overserved and Other Areas, 2008:
Table 6: Selected Physician Service Categories per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved and Other Areas, 2008:
Table 7: Selected Physician Services per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved and Other Areas, 2008:
Table 8: Selected CAHPS Survey Questions Related to Beneficiary Access
to Physician Services, 2008:
Table 9: Geographic Area Types for Utilization Analysis:
Table 10: Distribution of Geographic Areas by Ranking:
Table 11: Average Utilization by Geographic Area Type:
Table 12: Utilization Status of Geographic Areas:
Table 13: Selected Physician Services Provided per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved Areas and Other Areas:
Table 14: Utilization Status of Medicare Physician Payment Localities:
Table 15: Selected Physician Services Provided per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved and Other Medicare Physician
Payment Localities:
Table 16: Utilization Status of Hospital Referral Regions:
Table 17: Selected Physician Services Provided per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved and Other Hospital Referral
Regions:
Figures:
Figure 1: Percentage of Medicare Beneficiaries Receiving Physician
Services in April, 2000-2008:
Figure 2: Change from 2000 to 2008 in Proportion of Medicare
Beneficiaries Receiving Physician Services in April, by State Urban and
Rural Areas:
Figure 3: Number of Physician Services Provided per 1,000 Medicare
Beneficiaries Served in April, 2000-2008:
Figure 4: Change from 2000 to 2008 in Number of Physician Services
Provided per 1,000 Medicare Beneficiaries Served in April, by State
Urban and Rural Areas:
Figure 5: Numbers of Emergency Room Visits, Office Visits for New
Patients, and Office Visits for Established Patients per 1,000 FFS
Medicare Beneficiaries in April, 2000-2008:
Figure 6: Number of Physicians Billing Medicare for Services Provided
to Medicare Beneficiaries in April and Number of Medicare FFS
Beneficiaries, 2000-2007:
Figure 7: Proportion of Physician Services by Medicare Participation
and Assignment Status:
Figure 8: Geographic Areas by Type of Area and Utilization Status:
Abbreviations:
AMA: American Medical Association:
ARF: Area Resource File:
BETOS: Berenson-Eggers Type of Service:
CAHPS: Consumer Assessment of Healthcare Providers and Systems:
CBO: Congressional Budget Office:
CMS: Centers for Medicare & Medicaid Services:
CT: computed tomography:
EKG: electrocardiogram:
FFS: fee-for-service:
HRR: hospital referral region:
HRSA: Health Resources and Services Administration:
HSC: Center for Studying Health System Change:
MedPAC: Medicare Payment Advisory Commission:
MEI: Medicare Economic Index:
MRI: magnetic resonance imaging:
MSA: metropolitan statistical area:
NCH: National Claims History:
OMB: Office of Management and Budget:
SGR: sustainable growth rate:
UPIN: unique physician identification number:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
August 28, 2009:
The Honorable Max Baucus:
Chairman:
The Honorable Charles E. Grassley:
Ranking Member:
Committee on Finance:
United States Senate:
Over the last several years, rapid spending growth in Medicare Part B
services--driven in part by growth in physician services--has
heightened concerns regarding the Medicare program's fiscal
sustainability.[Footnote 1] According to the Medicare Trustees, despite
statutory controls on physician fee increases, spending for physician
services has steadily increased from about $32 billion in 1998 to about
$61 billion in 2008.[Footnote 2] Medicare fee-for-service (FFS) pays
for more than 7,000 physician services through an annually updated fee
schedule. Since the early 1990s, Congress, policy analysts, and groups
representing physicians have periodically questioned whether efforts to
control spending by limiting increases in physician fees could
undermine beneficiary access to physician services.
The Medicare physician fee schedule is updated annually by the
sustainable growth rate (SGR) system, with the intent of limiting the
total growth in Medicare spending for physician services over time.
Since the SGR's establishment, annual updates to physician fees have
varied and produced a 4.8 percent reduction in physician fees in 2002.
Congressional and administrative actions averted subsequent reductions
in physician fees for 2003 through 2009. However, concerns about access
remained as the fee updates during this period did not keep pace with
the growth in Medicare's estimated cost to physicians for providing
their services. Under current law, Medicare's fees to physicians are
projected to be reduced by about 21 percent in January 2010.[Footnote
3] Although these fee reductions may not occur if Congress intervenes,
the uncertainty surrounding physicians' Medicare fees points to the
ongoing need to monitor beneficiary access to physician services.
Our previous work has shown that this uncertainty about physician fees
has not been accompanied by reduced beneficiary access to physician
services, as measured by changes in FFS beneficiary utilization of
these services. In 2005, we reported that utilization of Medicare
physician services increased from 2000 to 2002 and that the 2002
reduction in physician fees did not appear to have an impact on
beneficiary access.[Footnote 4] In a 2006 report, we found no evidence
of a decrease in access from 2000 to 2005, as measured in terms of
utilization; our findings suggested that beneficiary access actually
increased.[Footnote 5] Specifically, during the years we studied,
relatively small proportions of beneficiaries reported problems
accessing physician services, the percentage of beneficiaries who
received physician services increased, and the number of services
provided per beneficiary increased as well.
Although these increases in utilization demonstrated that beneficiaries
were able to access physician services, our previous work did not
determine whether all of the increases in utilization we found were
appropriate. Wide geographic variation in Medicare spending for
physician services--unrelated to beneficiary health status or outcomes--
indicates that in some areas of the country, health needs alone may not
always determine the level of utilization of, and therefore the amount
of spending on, physician services.[Footnote 6] These areas may be
potentially overserved compared to other areas of the nation. Some
studies have shown that the provision of more care does not necessarily
mean better health care or better health outcomes for patients and in
some cases may lead to harm.[Footnote 7] Therefore, some of the
increased utilization of physician services that we identified in
previous studies may not have been warranted.
You raised questions about Medicare beneficiary access to physician
services, as well as questions about long-term fiscal challenges for
and inefficiency in Medicare. To obtain more information on these
topics, you asked us to provide an assessment of beneficiary access to
physician services and also to identify indicators of potential
beneficiary overutilization of physician services. This report (1)
examines whether, from 2000 through 2008, beneficiaries had problems
accessing physician services; (2) identifies areas of the country in
which Medicare beneficiaries are potentially overserved by physicians;
and (3) describes characteristics that distinguish the potentially
overserved areas from other areas in the nation.
To address the first objective, we constructed three types of
indicators to measure beneficiary access to physician services:
beneficiary perceptions about access, utilization of physician
services, and indicators of physician willingness to participate in
Medicare and serve Medicare beneficiaries. Beneficiary perceptions
about access were obtained from an analysis of the Consumer Assessment
of Healthcare Providers and Systems (CAHPS) survey data from 2007 and
2008. CAHPS is an annual Centers for Medicare & Medicaid Services (CMS)
patient satisfaction survey of Medicare beneficiaries.[Footnote 8]
Specifically, we examined beneficiary responses to two questions
related to access to physician services. The survey questions asked how
often an appointment for routine care was available as soon as the
respondent thought necessary and how often it was easy to obtain an
appointment with a specialist; our analysis was limited to
beneficiaries who needed such appointments. The possible responses were
"never," "sometimes," "usually," and "always." We considered
respondents to have reported a major access problem when they responded
"never" to one of the two survey questions. We analyzed utilization
trends by examining all Medicare claims for physician services provided
in the first 28 days of each April from 2000 through 2008.[Footnote 9],
[Footnote 10],[Footnote 11] Specifically, we calculated two measures of
utilization--the proportion of FFS beneficiaries receiving physician
services and the number of services per 1,000 beneficiaries who
received services. We examined these trends in both urban and rural
areas nationwide and in individual states.[Footnote 12] We also
examined trends in utilization of specific services, such as physician
office visits, from 2000 through 2008. We further utilized claims data
to analyze trends in the number of physicians billing Medicare and in
the proportion of services for which Medicare fees were accepted as
payment in full. (For more information on our scope and methodology,
see appendix I.)
To address our second objective, we identified areas of the country
where utilization of physician services in Medicare is potentially
excessive. Because policymakers have expressed concerns about both the
level and growth of services in the Medicare program, we incorporated
both factors in our measure of potential overservice.[Footnote 13]
Specifically, we identified areas that were both relatively high in
their level of utilization and relatively high in their growth in
utilization. Using U.S. Census Bureau[Footnote 14] and Office of
Management and Budget (OMB) classifications, we classified counties
into one of four types of geographic areas: metropolitan divisions,
large metropolitan statistical areas (MSA), small MSA areas, and rural
areas.[Footnote 15] Metropolitan divisions and large MSAs (MSAs with at
least 200,000 residents) each constituted a separate geographic area.
We combined smaller MSAs with other small MSAs within each state. We
designated counties outside of metropolitan divisions and MSAs as rural
and combined these rural areas within each state. This classification
process yielded 296 areas across the United States. To determine
utilization status, we measured utilization in each of these areas by
examining the number of services per beneficiary who received services
in April 2000 and April 2008. We ranked the areas by their level of
utilization in 2000 and the change in utilization from 2000 to 2008. We
then designated areas in the top half of both measures as "potentially
overserved" areas and the rest of the areas as "other" areas (for more
information on the rank of each area, see appendix III).[Footnote 16],
[Footnote 17]
To address the third objective, we reviewed literature to identify and
construct area-level characteristics that could drive the use of
physician services.[Footnote 18] We then compared potentially
overserved and other areas based on these characteristics.
Specifically, we examined demographic characteristics and the capacity
to provide health care services. We also compared beneficiary
satisfaction with their health care in the two groups of areas, as
measured by a beneficiary survey, and the types of physician services
provided in the two types of areas. To make these comparisons, we
obtained the most recent available data on demographic and health care
utilization capacity characteristics from the Area Resource File (ARF),
a national county-level health resource information database produced
by the Health Resources and Services Administration (HRSA) of the
Department of Health and Human Services; population and income data
from the U.S. Census Bureau; data on beneficiary experiences from the
2008 CAHPS survey; and utilization data from Medicare physician claims
from April 2008.[Footnote 19] We also analyzed and compared utilization
of specific types of physician services in potentially overserved and
other areas (see appendix IV for more information).[Footnote 20]
We took several steps to measure the reliability of data used in this
report. For the CAHPS and Medicare claims data, we reviewed the
documentation for both data sets, examined the accuracy and
completeness of the data, and interviewed experts to ensure that we
were using the data appropriately. The utilization information in
claims data is generally considered reliable, as the data are used by
the Medicare program to determine payment to health care providers and
are closely monitored by CMS and Medicare carriers. We also examined
the reliability of the U.S. Census Bureau and ARF data by reviewing
documentation and checking for obvious errors in the data sets. We
found all four data sources sufficiently reliable for this report.
We conducted this performance audit from May 2008 through August 2009
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background:
Since 1992, the Medicare program has used a resource-based fee schedule
to pay for physician services in the traditional FFS Medicare program.
The physician fee schedule includes three components: the relative
value for the service, a geographic adjustment, and a conversion
factor. The relative value for a service compares the resources
involved in performing one service with those of other services. There
are more than 7,000 physician services in the fee schedule and each one
is assigned a relative value. The geographic adjustment was designed to
ensure that fees appropriately:
reflect the geographic variation in costs associated with operating a
medical practice. Finally, the fee schedule uses a conversion factor
expressed in dollars to determine the payment rate for a particular
physician service.[Footnote 21] The conversion factor is updated
annually based on the SGR formula, which is set by law. The SGR is a
spending target system designed to control growth in spending
attributable to increases in the number of services, known as volume,
and to the services' complexity and costliness, known as intensity.
Although the SGR formula has called for negative physician fee updates
in recent years, Congress has mandated either no change or a positive
update that has been less than growth in the estimated cost to
physicians for providing their services.[Footnote 22] Beginning in
2010, physician fees are projected to be reduced by 21 percent,
according to the Congressional Budget Office (CBO).
Medicare generally pays physicians a predetermined amount for each
service provided. Physicians who "accept assignment" are those who
agree to accept Medicare's fee as payment in full. The fee includes the
coinsurance amount (usually 20 percent) paid by the beneficiary.
Physicians who sign Medicare participation agreements--referred to as
participating physicians--must accept assignment for all Medicare-
covered services that they provide to beneficiaries. Physicians who do
not sign participation agreements--referred to as nonparticipating
physicians--can either opt to accept assignment on a service-by-service
basis or not at all. When a nonparticipating physician accepts
assignment, the fee schedule amount, also known as the Medicare-
approved amount, is reduced by 5 percent. Medicare pays the physician
80 percent of the reduced amount; the beneficiary pays 20 percent of
the reduced amount. When a nonparticipating physician does not accept
assignment, the Medicare-approved amount is also reduced by 5 percent,
but the physician may collect from beneficiaries a portion of the
difference between his or her charge and the Medicare-approved amount--
a practice known as balance billing.[Footnote 23],[Footnote 24]
Access to Physician Services:
Several recent surveys of Medicare beneficiary access to physician
services have not identified major access issues. For example, a 2008
Medicare Payment Advisory Commission (MedPAC) survey,[Footnote 25] a
2007 Center for Studying Health System Change (HSC) survey, a 2007
Commonwealth Fund survey, and a 2007 AARP survey all concluded that
Medicare beneficiaries had few problems obtaining physician services.
[Footnote 26] MedPAC found that most beneficiaries were able to
schedule timely routine appointments and find a new physician when
needed. Additionally, Medicare beneficiaries reported similar or better
access to physician services compared to individuals covered by private
insurance, according to MedPAC, HSC, Commonwealth Fund, and AARP
surveys. Both the Commonwealth Fund and AARP also found that Medicare
beneficiaries are more likely than those with private insurance to
report high levels of satisfaction with their health care and access to
physicians.
Geographic Variation in the Utilization of Physician Services:
Physician spending under the Medicare program has historically grown at
a rapid pace, at times reaching double-digit increases, but these
increases may not mean better health care or better outcomes for
beneficiaries. Specifically, some of the higher volume and intensity
that drive spending growth may not be medically necessary. Physicians
have a financial incentive to perform as many services as possible
because Medicare pays them a fee for each service provided, with little
accountability for quality or efficiency. The Senate Finance Committee
has stated that the combination of high health care spending and
lagging quality is unsustainable for both the government and patients.
[Footnote 27]
Several studies of geographic variation in Medicare spending have
concluded that some utilization may not be warranted. A February 2008
CBO report found that per capita Medicare spending varied substantially
among states, ranging in 2004 from $4,000 in Utah to $6,700 in
Massachusetts.[Footnote 28] CBO found that the price paid for health
care services and severity of illness were important factors, but cited
research indicating that these two factors together likely account for
less than half of the geographic variation in spending. CBO also found
that patient preferences and income appear to explain little of the
variation and concluded that some variation in medical practice may be
attributable to differences in the supply of medical resources, such as
specialist physicians.
Several studies from Dartmouth have found that Medicare beneficiaries
living in areas with high levels of health care spending and
utilization do not experience better health outcomes or quality of
care. One Dartmouth study noted that Medicare spending would fall by 29
percent if spending levels in the lowest decile of areas were realized
in all higher spending regions.[Footnote 29] Dartmouth researchers
concluded that geographic variation in Medicare spending can be
attributed to how physicians respond to technology, capital, and other
resources under FFS.[Footnote 30] For example, physicians in higher-
spending regions were more likely than those in lower-spending regions
to recommend discretionary services and more resource-intensive
services.[Footnote 31] Clinical decisions are associated with physician
discretion when the evidence does not point clearly to a correct action
in a specific clinical situation. In a review of 2,500 treatments for a
variety of medical conditions, more than half were subject to physician
discretion.[Footnote 32]
Congress has recently shown an interest in varying annual Medicare
physician payment updates by geographic area. In the Deficit Reduction
Act of 2005, Congress directed MedPAC to examine alternatives to the
current payment system, including options that varied payment updates
by geographic areas.[Footnote 33] In a 2007 study, MedPAC found that
setting fee update amounts by geographic area would recognize that
practice patterns differ regionally and therefore have different
contributions to overall growth in volume and spending.[Footnote 34]
MedPAC suggested that regional updates would improve equity across the
nation and could help reduce geographic variation over time. Congress
has also held hearings on revising the method used to update physician
payments, and the Chairman of the Senate Finance Committee has stated
that reforming physician payment is an important component of health
care reform.[Footnote 35]
Indicators Show Few Problems in Beneficiary Access to Physician
Services:
Together, the three types of indicators we reviewed show that Medicare
beneficiaries experienced few problems accessing physician services.
Small percentages of Medicare beneficiaries reported never easily
obtaining appointments; measures of beneficiaries receiving physician
services increased nationwide from 2000 to 2008; and indicators of
physician willingness to serve Medicare beneficiaries and to accept
Medicare fees as payment in full also increased from 2000 to 2008.
Few Beneficiaries Reported Major Access Problems in 2007 and 2008:
Few Medicare beneficiaries reported major difficulties accessing
physician services in 2007 and 2008. (See table 1.) Specifically, among
those who needed routine care, very small percentages of beneficiaries
reported that it was never easy to schedule an appointment as soon as
they felt they needed it--2.5 percent in 2007 and 2.4 percent in 2008.
Similarly, in both 2007 and 2008, 2.1 percent of beneficiaries who
needed to see a specialist reported that it was never easy to get
appointments with specialists when needed. Nationwide, the percentages
of beneficiaries who reported major difficulties accessing routine or
specialist care were the same for those living in urban areas and in
rural areas in 2008--2.4 percent for routine care and 2.1 percent for
specialist care. Within every state and the District of Columbia, less
than 5 percent of the beneficiaries reported major difficulties
accessing physician services in 2008. For example, the proportion of
beneficiaries who reported never being able to easily schedule an
appointment with a specialist in 2008 ranged from 0.3 percent in North
Dakota to 4.7 percent in New Mexico. The proportion of beneficiaries
who reported it was never easy to promptly schedule an appointment for
routine care ranged from 1.5 percent in Oregon to 4.0 percent in
Alaska.
Table 1: Medicare Beneficiaries Who Reported Major Difficulties
Accessing Physician Services, 2007-2008:
CAHPS survey questions regarding access to physician services: In the
last 6 months, not counting the times you needed care right away, how
often did you get an appointment for your health care at a doctor's
office or clinic as soon as you thought you needed?
Percentage of respondents who reported having major difficulties:
2007: 2.5;
2008: 2.4.
CAHPS survey questions regarding access to physician services: In the
last 6 months, how often was it easy to get appointments with
specialists?
Percentage of respondents who reported having major difficulties:
2007: 2.1;
2008: 2.1.
Source: GAO analysis of Medicare CAHPS surveys from CMS.
Notes: We defined major difficulties as reporting "never" being able to
schedule an appointment for routine care or with a specialist in the
past 6 months. The total number of individuals responding to each
question varied from year to year. We reported proportions only for
those beneficiaries who stated a need to schedule an appointment for
routine care or see a specialist.
[End of table]
Proportion of Beneficiaries Receiving Physician Services Increased from
2000 to 2008:
In general, the proportion of beneficiaries who received physician
services rose during the period covered by our review. (See figure 1.)
Specifically, from 2000 to 2008, the proportion of beneficiaries
receiving services during the month of April rose from about 46 percent
to about 50 percent. Although the proportion of beneficiaries receiving
physician services increased from 2000 to 2008, the rate of increase
was not constant. The measure declined slightly in April 2003, but the
proportion of beneficiaries receiving services remained about one
percentage point higher than in April 2000, and the upward trend
resumed in 2004. Nationwide, this measure increased in both urban and
rural areas.[Footnote 36] Specifically, the proportion of beneficiaries
receiving services rose from about 47 percent in April 2000 to about 51
percent in April 2008 in urban areas and from about 42 percent in April
2000 to about 45 percent in April 2008 in rural areas.
Figure 1: Percentage of Medicare Beneficiaries Receiving Physician
Services in April, 2000-2008:
[Refer to PDF for image: three vertical bar graphs]
Year: 2000;
Total: 45.5%;
Urban: 46.7%;
Rural: 42.2%.
Year: 2001;
Total: 46.6%;
Urban: 47.8%;
Rural: 43.4%.
Year: 2002;
Total: 47.7%;
Urban: 48.9%;
Rural: 44.4%.
Year: 2003;
Total: 46.6%;
Urban: 47.9%;
Rural: 42.8%.
Year: 2004;
Total: 47.7%;
Urban: 48.9%;
Rural: 44.1%.
Year: 2005;
Total: 49.1%;
Urban: 50.6%;
Rural: 45.2%.
Year: 2006;
Total: 49.2%;
Urban: 50.7%;
Rural: 45.2%.
Year: 2007;
Total: 49.6%;
Urban: 51.1%;
Rural: 45.4%.
Year: 2008;
Total: 49.7%;
Urban: 51.3%;
Rural: 45.4%.
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Note: Beneficiaries were included in the count if they received a
service in the first 28 days of April and their claim was processed by
the end of the third quarter of each calendar year.
[End of figure]
From 2000 through 2008, the proportions of beneficiaries receiving
services in April varied by state urban and rural areas. For example,
in April 2000, the proportion of beneficiaries served ranged from 28.4
percent in rural Alaska to 51.8 percent in urban Pennsylvania. In April
2008, the proportion of beneficiaries served ranged from 32.7 percent
in rural Alaska to 57.5 percent in urban Florida.
Within 88 of the 99 urban and rural areas we examined, the proportion
of beneficiaries receiving services increased from April 2000 to April
2008. (See figure 2.) The largest increase in the percentage of
beneficiaries receiving services was 7.9 percentage points in rural
Maryland. There was a slight decline--less than 1 percentage point--in
six areas: rural California, rural Colorado, rural Idaho, urban Maine,
rural Montana, and rural Oregon. The largest decline in the proportion
of beneficiaries served--about 2 percentage points--occurred in rural
New Hampshire and rural Hawaii.
Figure 2: Change from 2000 to 2008 in Proportion of Medicare
Beneficiaries Receiving Physician Services in April, by State Urban and
Rural Areas:
[Refer to PDF for image: map of the United States]
The following areas are represented on the map:
Urban areas within states and areas with:
-2.02 to -0.01 percentage point change;
0.00 to 1.99 percentage point change;
2.00 to 3.99 percentage point change;
4.00 to 7.93 percentage point change.
Source: GAO analysis of CMS‘s Medicare Part B claims data and
enrollment data.
Notes: Beneficiaries were included in the count if they received a
service in the first 28 days of April and their claim was processed by
the end of the third quarter of each calendar year. There were no rural
areas in New Jersey, Rhode Island, and the District of Columbia.
[End of figure]
Average Number of Physician Services Provided per Beneficiary Rose from
2000 to 2008:
From April 2000 to April 2008, an increasing number of services were
provided to beneficiaries who were treated by a physician. (See figure
3.) Specifically, in that period, the average number of services
provided per 1,000 beneficiaries who were treated increased by about 15
percent--from about 3,400 to about 3,900. From April 2000 through April
2008, the number of services provided per 1,000 beneficiaries who were
treated was lower in rural areas relative to urban areas. However, in
percentage terms, the urban and rural areas experienced similar
increases in the number of services per 1,000 treated beneficiaries--
about a 17 percent increase in urban areas (from about 3,500 in April
2000 to about 4,100 in April 2008) and about a 13 percent increase in
rural areas (from about 3,200 in April 2000 to about 3,600 in April
2008).
Figure 3: Number of Physician Services Provided per 1,000 Medicare
Beneficiaries Served in April, 2000-2008:
[Refer to PDF for image: 3 vertical bar graphs]
Year: 2000;
Total: 3,430;
Urban: 3,514;
Rural: 3,194.
Year: 2001;
Total: 3,535;
Urban: 3,622;
Rural: 3,286.
Year: 2002;
Total: 3,630;
Urban: 3,723;
Rural: 3,356.
Year: 2003;
Total: 3,669;
Urban: 3,766;
Rural: 3,371.
Year: 2004;
Total: 3,710;
Urban: 3,806;
Rural: 3,420.
Year: 2005;
Total: 3,851;
Urban: 3,957;
Rural: 3,526.
Year: 2006;
Total: 3,905;
Urban: 4,013;
Rural: 3,576.
Year: 2007;
Total: 3,943;
Urban: 4,053;
Rural: 3,606.
Year: 2008;
Total: 3,944;
Urban: 4,054;
Rural: 3,602.
Source: GAO analysis of Medicare Part B claims data from CMS.
Note: Beneficiaries and services were included in the count if the
service was received in the first 28 days of April and the claim was
processed by the end of the third quarter of each calendar year.
[End of figure]
The number of services provided also varied among states' urban areas
and rural areas. For example, in April 2000, the number of services per
1,000 beneficiaries served ranged from about 2,800 in rural Utah to
about 3,900 in urban Texas. In April 2008, the number of services per
1,000 beneficiaries served ranged from about 3,100 in rural Hawaii to
about 4,500 in urban Florida.
Within every state's urban and rural areas, there was an increase from
April 2000 to April 2008 in the average number of services provided for
each beneficiary who was treated by a physician. (See figure 4.) In 59
of the 99 areas we examined, the number of services provided per 1,000
beneficiaries increased by about 12 percent or more. Among the 51 urban
areas we examined, the percentage increase in the number of services
provided per 1,000 beneficiaries ranged from about 5 percent in Vermont
to about 24 percent in New York. Among the 48 rural areas, the increase
ranged from about 1 percent in Alaska to about 23 percent in
Connecticut.
Figure 4: Change from 2000 to 2008 in Number of Physician Services
Provided per 1,000 Medicare Beneficiaries Served in April, by State
Urban and Rural Areas:
[Refer to PDF for image: map of the United States]
The following areas are represented on the map:
Urban areas within states and areas with:
1.3 to 10.4 percentage point change;
10.5 to 12.8 percentage point change;
12.9 to 14.3 percentage point change;
14.4 to 23.7 percentage point change.
Source: GAO analysis of CMS‘s Medicare Part B claims data.
Notes: Beneficiaries and services were included in the count if the
service was received in the first 28 days of April and the claim was
processed by the end of the third quarter of each calendar year. There
were no rural areas in New Jersey, Rhode Island, and the District of
Columbia.
[End of figure]
The average number of physician office visits--an indicator of
beneficiary access to the typical entry point into the health care
system and most basic level of physician services--rose for Medicare
beneficiaries from April 2000 to April 2008. (See figure 5.) The number
of office visits increased during that period from about 29 to 31
(about 7 percent) per 1,000 Medicare beneficiaries for new patients and
from about 442 to 504 (about 14 percent) per 1,000 Medicare
beneficiaries for established patients. Research indicates that an
increased number of emergency room visits above the growth in physician
services could signify problems accessing primary care because patients
who have difficulties obtaining routine care may instead seek health
care in emergency rooms.[Footnote 37] However, our analysis
demonstrates similar increases in emergency room visits, total office
visits, and overall physician services from 2000 to 2008. Specifically,
emergency room visits rose from about 34 to 39 per 1,000 beneficiaries--
about 15 percent--which was approximately equal to the increase in
total (new and established patient) office visits and the increase in
the overall number of physician services per 1,000 beneficiaries
treated.
Figure 5: Numbers of Emergency Room Visits, Office Visits for New
Patients, and Office Visits for Established Patients per 1,000 FFS
Medicare Beneficiaries in April, 2000-2008:
[Refer to PDF for image: multiple vertical bar graph]
Year: 2000;
Emergency room visits: 34;
Office visits for new patients: 29;
Office visits for established patients: 442.
Year: 2001;
Emergency room visits: 37;
Office visits for new patients: 29;
Office visits for established patients: 456.
Year: 2002;
Emergency room visits: 38;
Office visits for new patients: 31;
Office visits for established patients: 475.
Year: 2003;
Emergency room visits: 38;
Office visits for new patients: 30;
Office visits for established patients: 462.
Year: 2004;
Emergency room visits: 38;
Office visits for new patients: 28;
Office visits for established patients: 473.
Year: 2005;
Emergency room visits: 40;
Office visits for new patients: 30;
Office visits for established patients: 497.
Year: 2006;
Emergency room visits: 40;
Office visits for new patients: 30;
Office visits for established patients: 494.
Year: 2007;
Emergency room visits: 40;
Office visits for new patients: 30;
Office visits for established patients: 497.
Year: 2008;
Emergency room visits: 39;
Office visits for new patients: 31;
Office visits for established patients: 504.
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Note: Beneficiaries and services were included in the count if the
service was received in the first 28 days of April and the claim was
processed by the end of the third quarter of each calendar year.
[End of figure]
Indicators of Physician Willingness to Serve Medicare Beneficiaries
Remain Favorable:
Two additional access-related indicators--the number of physicians
billing Medicare for services and the percentage of services for which
Medicare's fees were accepted as payment in full--increased since 2000.
(See figure 6.) Specifically, the number of physicians billing Medicare
increased from about 419,000 in April 2000 to about 474,000 in April
2007.[Footnote 38] The number of physicians continued to increase even
as the number of beneficiaries in Medicare FFS declined over the last 2
years. The number of beneficiaries in traditional FFS Medicare
decreased from about 33.4 million in 2005 to about 31.9 million in
2007, as more beneficiaries joined Medicare Advantage plans.[Footnote
39] Increases in the number of physicians billing Medicare, in spite of
the decline in Medicare FFS beneficiaries, suggest that in the
aggregate, physicians continued to accept FFS Medicare patients during
this period.
Figure 6: Number of Physicians Billing Medicare for Services Provided
to Medicare Beneficiaries in April and Number of Medicare FFS
Beneficiaries, 2000-2007:
[Refer to PDF for image: vertical bar graph and line graph]
Year: 2000
Physicians: 419,000;
Number of FFS beneficiaries: 29.8 million.
Year: 2001
Physicians: 427,000;
Number of FFS beneficiaries: 30.8 million.
Year: 2002
Physicians: 437,000;
Number of FFS beneficiaries: 31.8 million.
Year: 2003
Physicians: 447,000;
Number of FFS beneficiaries: 32.5 million.
Year: 2004
Physicians: 454,000;
Number of FFS beneficiaries: 33 million.
Year: 2005
Physicians: 466,000;
Number of FFS beneficiaries: 33.4 million.
Year: 2006
Physicians: 472,000;
Number of FFS beneficiaries: 32.6 million.
Year: 2007
Physicians: 474,000;
Number of FFS beneficiaries: 31.9 million.
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS.
Notes: Physicians were included in the count if they served a
beneficiary in the first 28 days of April and their claim was processed
by the end of the third quarter of each calendar year. We counted each
occurrence of the unique physician identification number on the claim
once.
[End of figure]
From April 2000 to April 2008, the majority of Medicare physician
services were performed by physicians who accepted Medicare's fees as
payment in full. (See figure 7.) In April 2000, about 98 percent of
physician services were performed by physicians who accepted Medicare's
fee as payment in full (on assignment), and in April 2008, about 99
percent of physician services were paid on assignment. A smaller share
of beneficiaries were likely subject to balance billing for physician
services in April 2008 than in April 2000, as the percentage of
services for which physicians did not accept Medicare's fee as payment
in full decreased from about 1.8 percent to about 0.7 percent. The
proportion of services provided by participating physicians--that is,
physicians who formally agreed to participate in the Medicare program
and submit all claims on assignment--increased from about 95 percent in
April 2000 to about 97 percent in April 2008.[Footnote 40]
Figure 7: Proportion of Physician Services by Medicare Participation
and Assignment Status:
[Refer to PDF for image: two pie-charts]
April 2000:
Participating/assigned: 95%;
Nonparticipating/assigned: 3.2%;
Nonparticipating/unassigned: 1.8%.
April 2008:
Participating/assigned: 97.2%;
Nonparticipating/assigned: 2.1%;
Nonparticipating/unassigned: 0.7%.
Source: GAO analysis of Medicare Part B claims data from CMS.
Note: Services were counted if they were received in the first 28 days
in April and claims for these services were processed by the end of the
third quarter of each calendar year.
[End of figure]
Potentially Overserved Areas Tend to Be in More Densely Populated Urban
Regions and the Eastern Part of the Country:
Potentially overserved areas tend to be the more densely populated
urban regions. Higher population density tended to increase an area's
likelihood of being potentially overserved. Nearly half of the 32
metropolitan divisions--the most densely populated group of areas--were
potentially overserved. (See table 2.) Similarly, a little more than a
quarter of large MSAs were potentially overserved while among small MSA
areas and rural areas, barely 1 in 10 was potentially overserved.
[Footnote 41]
Table 2: Distribution of Utilization Status by Type of Geographic Area:
Type of geographic area: Metropolitan divisions;
Number of areas: 32;
Percentage: Potentially overserved areas: 47;
Percentage: Other areas: 53.
Type of geographic area: Large MSAs;
Number of areas: 174;
Percentage: Potentially overserved areas: 27;
Percentage: Other areas: 73.
Type of geographic area: Small MSA areas;
Number of areas: 43; Percentage: Potentially overserved areas: 12;
Percentage: Other areas: 88.
Type of geographic area: Rural areas;
Number of areas: 47;
Percentage: Potentially overserved areas: 11;
Percentage: Other areas: 89.
Type of geographic area: All areas;
Number of areas: 296;
Percentage: Potentially overserved areas: 24;
Percentage: Other areas: 76.
Source: GAO analysis of data from the U.S. Census Bureau and Medicare
Part B claims and enrollment data for April 2000 and April 2008 from
CMS.
Notes: Connecticut, the District of Columbia, New Jersey and Rhode
Island had no rural areas. Counties were mapped to metropolitan
divisions based on U.S. Census Bureau designations. Nonrural counties
outside of metropolitan divisions were mapped to MSAs based on U.S.
Census Bureau and OMB designations. Small MSA areas are MSAs with fewer
than 200,000 in population grouped together within each state. Rural
areas include all rural counties within a state.
[End of table]
Of the 296 geographic areas we examined, about one in four was
potentially overserved--that is, they were in the top half of areas in
both utilization of physician services in 2000 and growth in
utilization of these services from 2000 to 2008. Areas that were in the
top half in utilization in 2000 were nearly as likely to be in the top
half in growth from 2000 to 2008 as areas that started in the bottom
half in utilization. Specifically, of the 148 areas that were in the
top half in utilization in 2000, 72 were in the top half in growth from
2000 to 2008. (See table 10 in appendix I.) Similarly, of the 148 areas
that were in the bottom half in utilization in 2000, 76 were in the top
half in growth from 2000 to 2008.
Potentially overserved areas and other areas experienced wide
differences in utilization. These differences tended to be widest in
the more densely populated regions. In 2000, the average number of
services per beneficiary who received services was 3.58 in potentially
overserved areas versus 3.24 in other areas, or a difference of more
than 10 percent. (See appendix II for more information on utilization
by type of geographic area.) Among areas with the largest populations--
the metropolitan divisions and large MSAs--average utilization in 2000
was 9 percent higher in potentially overserved areas, compared with a
difference of about 5 percent among small MSA areas and 8 percent among
rural areas. The growth in utilization from 2000 to 2008 displayed a
similar pattern. Overall, the average increase for potentially
overserved areas was nearly 18 percent, while for other areas it was
just over 12 percent. The average increase in utilization in
potentially overserved metropolitan divisions was 21 percent, compared
with 12 percent in other metropolitan divisions. For the less densely
populated areas, utilization also grew more rapidly in potentially
overserved areas, although the gap in growth rates between potentially
overserved and other areas tended to be smaller than it was for the
metropolitan divisions. For example, the average increase in
utilization was 17 percent in potentially overserved large MSAs,
compared with 13 percent for other large MSAs.
Our analysis found that areas in states east of the Mississippi River
were much more likely to be potentially overserved. (See figure 8.) Of
the 174 areas in states that are east of the Mississippi River, 60 were
potentially overserved. For example, nearly the entire states of
Alabama, Florida, and Illinois comprised potentially overserved areas.
Of the 122 areas in states that are west of the Mississippi River, only
12 were potentially overserved[Footnote 42].
Figure 8: Geographic Areas by Type of Area and Utilization Status:
[Refer to PDF for image: map of the United States]
The map depicts the following types of areas:
Potentially overserved rural areas;
Potentially overserved small MSA areas;
Potentially overserved large MSAs;
Potentially overserved metropolitan divisions;
Other areas.
Source: GAO analysis of 2006 U.S. Census Bureau data and Medicare Part
B claims data for April 2000 and April 2008.
Notes: We classified U.S. counties into one of four types of geographic
areas: metropolitan divisions, large MSAs, small MSA areas, and rural
areas. Potentially overserved areas are areas that were in the top half
of areas in both utilization of physician services in 2000 and growth
in utilization of physician services from 2000 to 2008. The rest of the
areas were designated as other areas.
[End of figure]
Beneficiaries residing east of the Mississippi River are much more
likely to reside in a potentially overserved area, because the most
densely populated areas in the east are more likely to be potentially
overserved than are those in the west. In 2008 nearly half the
beneficiaries who resided in a state east of the Mississippi River were
in a potentially overserved area, while in the western part of the
country only 1 beneficiary in 10 resided in a potentially overserved
area. In terms of population, the largest of the major metropolitan
divisions east of the Mississippi River, including New York-White
Plains, Chicago-Naperville-Joliet, and Philadelphia, were potentially
overserved areas.[Footnote 43] In contrast, the largest western
metropolitan divisions of Los Angeles-Long Beach-Glendale, Dallas-
Plano-Irving, and Santa Ana-Anaheim-Irvine were not potentially
overserved areas by our measure.[Footnote 44] Similarly, beneficiaries
in five of the six most populous large MSAs in the east were in
potentially overserved areas, while beneficiaries in five of the six
most populous large MSAs in the west were not. Only a minority of small
MSA areas and rural areas in the east were potentially overserved and
none of either of these two area types were potentially overserved in
the west. (See appendix III for a list of all areas.)[Footnote 45]
Potentially Overserved Areas Are Largely Similar to Other Areas, with
the Exception of Physician Practice Patterns:
Potentially overserved areas and other areas are largely similar in
characteristics that could drive the use of physician services,
including demographic characteristics and the capacity to provide
health care services. In contrast, certain types of physician services
are performed more frequently in potentially overserved areas than in
other areas, suggesting differences in physician practice patterns.
Demographic Characteristics and Capacity to Provide Health Care Are
Similar among Potentially Overserved and Other Areas:
Potentially overserved and other areas appear similar in demographic
characteristics that could be expected to affect the use of physician
services. (See table 3.) For example, in 2006 Medicare beneficiaries in
both groups of areas had similar risk scores, meaning they are expected
to require similar amounts of Medicare resources because of their
health status.[Footnote 46] Potentially overserved areas and other
areas also had a similar racial composition and average income levels,
although they differed somewhat in educational attainment.[Footnote 47]
While these local factors are not under the control of the health care
delivery system, they could be expected to influence the utilization of
health care services. For example, income levels and insurance coverage
have been shown to be related to patient preferences and demand for
health care.[Footnote 48]
Table 3: Selected Demographic Characteristics in Potentially Overserved
and Other Areas:
Deaths per 1,000 people, 2006:
Potentially overserved areas: 8.8;
Other areas: 8.1.
Average risk score, 2006[A]:
Potentially overserved areas: 1.03;
Other areas: 0.98.
Average Medicare beneficiary age, 2008:
Potentially overserved areas: 71.2;
Other areas: 70.8.
Income per capita, 1999:
Potentially overserved areas: $21,315;
Other areas: $21,653.
Percentage of population enrolled in Medicare, 2007:
Potentially overserved areas: 11.7;
Other areas: 10.8.
Percentage of Medicare beneficiaries reporting having insurance in
addition to Medicare:
Potentially overserved areas: 75;
Other areas: 77.
Percentage of population nonwhite, 2006:
Potentially overserved areas: 19.0;
Other areas: 18.6.
Percentage of population with at least 4 years of college education,
2006:
Potentially overserved areas: 22.9;
Other areas: 25.5.
Source: GAO analysis of Medicare Part B claims data, enrollment data,
CAHPS survey data, and Medicare Advantage rate calculation data from
CMS; ARF data from HRSA; and data from the U.S. Census Bureau.
Notes: Data were the most recent available at the time of our analysis.
We classified U.S. counties into one of four types of geographic areas:
metropolitan divisions, large MSAs, small MSA areas, and rural areas.
Potentially overserved areas are areas that were in the top half of
areas in both utilization of physician services in April 2000 and
growth in utilization of physician services from April 2000 to April
2008. The rest of the areas were designated as other areas.
[A] The risk scores are based on the demographics and diagnoses of the
entire FFS population in a county and reflect the likelihood of needing
more expensive care for Medicare Parts A and B combined. The population
we used to determine whether an area is potentially overserved consists
of beneficiaries who received Part B physician services in April 2000
or April 2008.
[End of table]
Potentially overserved areas and other areas are also similar in terms
of their capacities to provide health care services, as measured by
number of beds and physicians per 1,000 people. (See table 4.)
Specifically, in 2005, potentially overserved and other areas had a
similar number of hospital beds per 1,000 people. In 2004, potentially
overserved areas and other areas also had a similar number of
physicians per 1,000 people. Studies have demonstrated strong
associations between the number of hospital beds and hospital
utilization and between physician supply and the rate of physician
visits.[Footnote 49]
Table 4: Selected Health Care Capacity Characteristics in Potentially
Overserved and Other Areas:
Hospital beds per 1,000 population, 2005:
Potentially overserved areas: 3.4;
Other areas: 3.5.
Short-term hospital inpatient days per Medicare beneficiary, 2005:
Potentially overserved areas: 2.3;
Other areas: 2.0.
Number of physicians per 1,000 people, 2004:
Potentially overserved areas: 2.8;
Other areas: 2.8.
Ratio of primary care physicians to specialists, 2004:
Potentially overserved areas: 0.5;
Other areas: 0.5.
Source: GAO analysis of ARF data from HRSA.
Notes: Data were the most recent available at the time of our analysis.
We classified U.S. counties into one of four types of geographic areas:
metropolitan divisions, large MSAs, small MSA areas, and rural areas.
Potentially overserved areas are areas that were in the top half of
areas in both utilization of physician services in April 2000 and
growth in utilization of physician services from April 2000 to April
2008. The rest of the areas were designated as other areas.
[End of table]
As table 4 shows, in 2004, potentially overserved areas and other areas
had similar numbers of primary care physicians compared to specialists--
about a one-to-two ratio. Studies have shown that areas with higher
ratios of primary care physicians to specialists have better health
outcomes and better meet quality measures, such as administering beta-
blockers after a heart attack or performing regular eye exams on
diabetic patients.[Footnote 50] Conversely, studies have demonstrated
that areas with more specialty services are associated with higher
spending but not better access or health outcomes.[Footnote 51]
Beneficiary Satisfaction Is Similar in Potentially Overserved and Other
Areas:
Potentially overserved areas and other areas have similar Medicare
beneficiary satisfaction, as measured by beneficiary perceptions of
health care and health status. (See table 5.) For example, 94 percent
of beneficiaries in potentially overserved areas reported having a
personal doctor, compared to 93 percent of beneficiaries in other
areas. Beneficiaries in both groups of areas also reported similar
average health status, and similarly rated their health care and
personal doctors highly. This finding is consistent with studies
showing that geographic areas with high Medicare spending do not have
better outcomes or perceptions of quality of medical care.[Footnote 52]
Table 5: Selected Medicare Beneficiary Satisfaction Indicators in
Potentially Overserved and Other Areas, 2008:
Percentage reporting having a personal doctor;
Potentially overserved areas: 94:
Other areas: 93.
Percentage reporting that it was never easy to schedule an appointment
with a specialist:
Potentially overserved areas: 2;
Other areas: 2.
Percentage reporting never being able to promptly schedule an
appointment for routine care:
Potentially overserved areas: 2;
Other areas: 2.
Self-reported health status (1 = Excellent, 3 = Good, 5 = Poor):
Potentially overserved areas: 3.1;
Other areas: 3.1.
Average rating of personal doctor (0 = worst, 10= best):
Potentially overserved areas: 8.9;
Other areas: 8.9.
Average rating of overall health care (0 = worst, 10 = best):
Potentially overserved areas: 8.3;
Other areas: 8.4.
Source: GAO analysis of the Medicare CAHPS survey from CMS.
Notes: The total number of individuals responding to each question
varied. We report proportions of beneficiaries who were never able to
easily schedule an appointment for routine care with a doctor or a
specialist in the past 6 months only for those beneficiaries who needed
routine care or a specialist. Similarly, we report beneficiary ratings
of their personal doctor and overall health care only for those
beneficiaries who visited a personal doctor or received health care
services in the past 6 months. We classified U.S. counties into one of
four types of geographic areas: metropolitan divisions, large MSAs,
small MSA areas, and rural areas. Potentially overserved areas are
areas that were in the top half of areas in both utilization of
physician services in April 2000 and growth in utilization of physician
services from April 2000 to April 2008. The rest of the areas were
designated as other areas.
[End of table]
Potentially Overserved and Other Areas Have Substantial Differences in
Use of Certain Types of Physician Services:
When we compared types of physician services provided to Medicare
beneficiaries, we found that potentially overserved areas and other
areas differed in the frequency with which certain categories of
physician services are used. (See table 6.) Specifically, we found that
in April 2008, potentially overserved areas used substantially more
evaluation and management services, minor procedures, and imaging
services per 1,000 beneficiaries than other areas. For example,
potentially overserved areas had 44 percent more minor procedures--
which include services such as ambulatory procedures, eye procedure
treatments, and colonoscopies--per 1,000 beneficiaries than other
areas. Potentially overserved areas also had 29 percent more laboratory
tests and 19 percent more imaging services per 1,000 beneficiaries than
other areas. The two groups of areas, however, had similar rates of
major procedures. (See appendix IV for additional trends in selected
physician services in potentially overserved and other areas.)[Footnote
53]
Table 6: Selected Physician Service Categories per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved and Other Areas, 2008:
All services:
Potentially overserved areas: 2,247;
Other areas: 1,812.
Evaluation and management services:
Potentially overserved areas: 1,188;
Other areas: 969.
Procedures: Major[A]:
Potentially overserved areas: 25;
Other areas: 22.
Procedures: Minor[B]:
Potentially overserved areas: 191;
Other areas: 133.
Imaging services:
Potentially overserved areas: 457;
Other areas: 385.
Laboratory tests:
Potentially overserved areas: 44;
Other areas: 34.
Source: GAO analysis of Medicare Part B claims data and enrollment data
from CMS.
Notes: Beneficiaries and services were included in the count if the
service was received in the first 28 days of April and the claim was
processed by the end of the third quarter of each calendar year. We
classified U.S. counties into one of four types of geographic areas:
metropolitan divisions, large MSAs, small MSA areas, and rural areas.
Potentially overserved areas are areas that were in the top half of
areas in both utilization of physician services in 2000 and growth in
utilization of physician services from 2000 to 2008. The rest of the
areas were designated as other areas.
[A] Major procedures is a clinical category defined by CMS, and
includes physician services such as coronary artery bypass grafts, hip
fracture repairs, and knee replacements.
[B] Minor procedures is a clinical category defined by CMS, and
includes physician services such as ambulatory procedures, eye
procedure treatments, and colonoscopies.
[End of table]
We also found that specific services associated with the exercise of
physician discretion are performed more frequently in potentially
overserved areas, indicating differences in physician practice
patterns. (See table 7.) When there is not a universally accepted
treatment approach, the choice of services is subject to physician
discretion. Several studies have identified certain services as prone
to overuse or misuse for various reasons, including physician
discretion.[Footnote 54] Two of the three physician services identified
in the literature as being related to physician discretion were
performed substantially more frequently in potentially overserved areas
than in other areas in April 2008. Advanced imaging services, which
includes computed tomography (CT) and magnetic resonance imaging (MRI),
were 16.1 percent more prevalent per 1,000 beneficiaries in potentially
overserved areas than in other areas in April 2008.[Footnote 55]
Electrocardiograms (EKG) were performed 30.1 percent more frequently
per 1,000 beneficiaries in potentially overserved areas than in other
areas. However, the frequency of knee replacements was similar in
potentially overserved and other areas.[Footnote 56]
Table 7: Selected Physician Services per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved and Other Areas, 2008:
Services associated with physician discretion: Knee replacement[A]:
Potentially overserved areas: 0.8;
Other areas: 0.8.
Services associated with physician discretion: Advanced imaging[B]:
Potentially overserved areas: 74.8;
Other areas: 64.4.
Services associated with physician discretion: EKG[B]:
Potentially overserved areas: 85.2;
Other areas: 65.5.
Services not associated with physician discretion: Hip surgery for hip
fracture[C]:
Potentially overserved areas: 0.4;
Other areas: 0.4.
Services not associated with physician discretion: Colonoscopy for
cancer screening[C]:
Potentially overserved areas: 8.2;
Other areas: 7.4.
Services not associated with physician discretion: Cataract removal[D]:
Potentially overserved areas: 5.0;
Other areas: 5.1.
Source: GAO analysis of Medicare Part B claims data and enrollment data
from CMS, and GAO review of literature.
Notes: Beneficiaries and services were included in the count if the
service was received in the first 28 days of April and the claim was
processed by the end of the third quarter of each calendar year. We
classified U.S. counties into one of four types of geographic areas:
metropolitan divisions, large MSAs, small MSA areas, and rural areas.
Potentially overserved areas are areas that were in the top half of
areas in both utilization of physician services in 2000 and growth in
utilization of physician services from 2000 to 2008. The rest of the
areas were designated as other areas. Physician services associated
with physician discretion are situations in which there is not a
universally accepted approach to treating the diagnosis.
[A] Dartmouth researchers have identified knee replacement as an
example of preference-sensitive care, meaning interventions for which
there is a choice between at least two treatments that have different
risks and benefits. Treatment choices among preference-sensitive care
depend on patient preference and, often, physician discretion.
[B] Dartmouth researchers have identified imaging and diagnostic
testing as examples of supply-sensitive care, meaning care for which
supply of resources governs the frequency of use.
[C] Dartmouth researchers have identified hip surgery for hip fracture
and colonoscopy for cancer screening as examples of situations in which
there is a universally accepted approach to treating the diagnosis.
[D] Researchers at RAND identified cataract removal as a service with
low rates of inappropriate use.
[End of table]
We also found that two of three services identified in the literature
as being universally accepted approaches to diagnoses or having low
rates of inappropriate use were performed at similar frequencies in the
two groups of areas in April 2008. Specifically, hip surgery for hip
fracture and cataract removal were performed at similar frequencies in
the two groups of areas. However, colonoscopy for cancer screening--
another procedure identified in the literature as effective and
strongly supported by evidence--was performed 10.8 percent more often
per 1,000 beneficiaries in potentially overserved areas than in other
areas in the United States.
Concluding Observations:
Although concerns have been raised that Congress's efforts to control
spending on physician services could limit beneficiary access to those
services, our analysis suggests that beneficiary access generally
remained the same or increased from 2000 to 2008. These findings are
consistent with our earlier work. However, we also found that some
geographic areas of the country experienced much higher levels of
utilization of physician services and much greater increases in
utilization compared to the rest of the nation--which may indicate
excessive care not driven by medical need. Our definition of areas that
are potentially overserved was based on both levels of service and
growth rates, while past research has generally concentrated on levels
of service. Nevertheless, our findings are consistent with past
research--they underscore the importance of geography in the
utilization of physician services and can help inform ongoing
discussions regarding Medicare physician payment reform. Medicare's
SGR, which is used to help control spending on physician services, does
not account for geographic differences in utilization rates. As
Congress considers options for revising the SGR and other payment
reforms, the issue of geographic differences will likely continue to be
part of this discussion.
Agency and Industry Comments and Our Evaluation:
Agency Comments:
In written comments on a draft of this report, CMS noted the agency's
longstanding practice of monitoring the effect of policy changes on
beneficiary access to Medicare services, and stated that this report
would help in that effort. We have reprinted CMS's letter in appendix
IX.
American Medical Association Comments:
We obtained oral comments on a draft of our report from an official
representing the American Medical Association (AMA). The AMA official
shared two overall observations. First, the AMA official said that the
rate of growth in per beneficiary utilization of physician services had
declined each year since 2004. While the growth rate has not been
uniform, our report finds that an increasing number of services were
provided to beneficiaries who were treated by a physician from April
2000 to April 2008. Second, the AMA official said that beneficiaries
could face access problems that would not appear in our analysis of
survey and claims data. The AMA official explained, for example, that
physicians could increase the number of claims they submit, while
seeing fewer patients or could be accepting fewer Medicare
beneficiaries seeking new appointments. However, the three overall
indicators we constructed to measure access trends--from both the
beneficiary and physician perspective--demonstrated sustained
beneficiary access to services. As we reported in our draft, we found
very few beneficiaries reporting major access difficulties in 2007 and
2008, the utilization of services increased nationwide from April 2000
to April 2008, and physician participation in Medicare also rose over
this period. The AMA official also shared technical comments with us,
which we incorporated into our report as appropriate.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At the time, we will send copies to the Acting
Administrator of CMS and interested congressional committees. The
report also will be available at no charge on GAO's Web site at
[hyperlink, http://www.gao.gov].
If you or your staff have any questions, please contact me at (202) 512-
7114 or steinwalda@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this
report are listed in appendix X.
Signed by:
A. Bruce Steinwald:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
This appendix explains the scope and methodology that we used to
address our reporting objectives. Specifically, we wanted to (1)
determine how beneficiary access to physician services has changed from
2000 to 2008; (2) identify areas of the country where Medicare
beneficiaries are potentially overserved by physicians; and (3)
describe characteristics that distinguish potentially overserved areas
from other areas in the nation.
To determine how beneficiary access to physician services changed from
2000 to 2008, we constructed three types of indicators to measure
beneficiary access to physician services: beneficiary perceptions about
access, utilization of physician services, and indicators of
physicians' willingness to participate in Medicare and serve Medicare
beneficiaries. To measure beneficiary perceptions of access, we
analyzed 2007 and 2008 responses to the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) survey conducted by the
Centers for Medicare & Medicaid Services (CMS). We used CAHPS survey
data that asked beneficiaries to describe their experiences with the
Medicare fee-for-service (FFS) program.[Footnote 57] These annual
surveys are a nationally representative source of Medicare beneficiary
perceptions of their access to health care that would enable
comparisons over time among states and between urban and rural areas.
Respondents were asked about their experiences in the 6 months before
the survey.[Footnote 58] CMS surveyed approximately 431,000 FFS
beneficiaries in the spring of 2007 and approximately 306,000 in the
spring of 2008. We excluded responses from beneficiaries residing
outside the 50 states and the District of Columbia from our analysis.
The number of FFS beneficiaries residing in the areas that were part of
our analysis who completed the survey was 199,000 in 2007 and 163,000
in 2008.[Footnote 59]
We focused on two CAHPS questions that were related to beneficiary
access to physician services. The questions, reproduced in table 8,
asked about the ease of scheduling prompt appointments for routine care
and beneficiary ability to gain access to specialists. For each
question, we included only the responses from those beneficiaries who
could have encountered an access problem--that is, those who reported
trying to schedule an appointment with any doctor and those who
attempted to make an appointment to see a specialist. For example, we
include responses to the specialist access question only for those
beneficiaries who answered in a prior survey question that they needed
to see a specialist in the past 6 months. We calculated the proportion
of respondents who responded the most negatively--those who responded
that they were "never" able to schedule an appointment as soon as they
thought they needed it.
Table 8: Selected CAHPS Survey Questions Related to Beneficiary Access
to Physician Services, 2008:
Respondents included in analysis: Beneficiaries who reported making an
appointment at a doctor's office and clinic with the exception of those
who needed care right away;
Percentage of all survey respondents: 81;
Question: In the last 6 months, not counting the times you needed care
right away, how often did you get an appointment for your health care
at a doctor's office or clinic as soon as you thought you needed?
Possible responses: Never; Sometimes; Usually; Always.
Respondents included in analysis: Beneficiaries who reported trying to
make an appointment to see a specialist;
Percentage of all survey respondents: 53;
Question: In the last 6 months, how often was it easy to get
appointments with specialists?
Possible responses: Never; Sometimes; Usually; Always.
Source: GAO analysis of the 2008 Medicare CAHPS survey conducted by
CMS.
[End of table]
We also examined whether these responses varied by state or between
urban and rural areas nationwide.
To analyze Medicare beneficiary access to physician services based on
their utilization of services, we used Medicare Part B claims data from
the National Claims History (NCH) files. We constructed data sets for
100 percent of Medicare claims for physician services performed by
physicians in the first 28 days of April of 2000 through 2008, which
yielded more than 60 million claims per year.[Footnote 60] These claims
represent an annual snapshot of beneficiary access to physician
services for each of the 9 years. We selected April to allow time for
the annual fee updates to be implemented beginning January 1 and for
physician behavior to adjust to the new fees. To avoid "calendar bias"--
that is, the occurrence of more weekdays in April in one year compared
to another--and to create an equal number of weekdays in each year's
data set, we limited each year's claims to services performed within
the first 28 days of the month. These data encompass several periods: 2
years in which fee increases were greater than the increase in the
estimated cost of providing services (2000 and 2001), 1 year in which
fees decreased (2002), and 6 years in which fee increases were less
than the growth in the estimated cost of providing services (2003
through 2008).[Footnote 61] We established a consistent cutoff date
(the last Friday in September of each year) for each year's data file
and only included those claims for April services that had been
processed by that date.[Footnote 62] Because claims continue to accrete
in the data files, this step was necessary to ensure that earlier years
were not more complete than later years. To determine the number of FFS
beneficiaries, we used the April enrollment data from the Denominator
file--a database that contains enrollment data and entitlement status
for all Medicare beneficiaries enrolled, entitled, or both in each
month in a given year. In addition, on the basis of beneficiary
location, we associated each service with an urban or rural location,
using the Office of Management and Budget (OMB) classification of
metropolitan statistical areas (MSA). We constructed multiple
utilization measures to determine whether Medicare beneficiaries
experienced changes in their access to physician services; these
indicators included:
* the percentage of Medicare FFS beneficiaries obtaining services in
April of each year and:
* the number of physician services per 1,000 beneficiaries who received
services.
We analyzed these utilization measures nationally, for urban and rural
areas within each state, and for specific services, such as office
visits for new and established patients and emergency room visits.
Using MSAs, we classified the nation's counties as urban or rural,
consolidated the urban counties and rural counties in each state and
the District of Columbia, and created 99 geographic areas to analyze
access at a subnational level.[Footnote 63]
To indicate physicians' willingness to participate in Medicare, we
determined the number of physicians billing Medicare from 2000 through
2007,[Footnote 64] whether services were performed by participating or
nonparticipating physicians, and whether claims for physician services
were paid on assignment or not on assignment.[Footnote 65] We did not
adjust the data for factors that could affect the provision and use of
physician services, such as incidence of illness or coverage of new
benefits.
To identify areas of the country where Medicare beneficiaries are
potentially overserved by physicians, we identified areas of the
country where utilization of physician services in Medicare is
potentially excessive. Because policymakers have expressed concerns
about both the level and growth of services in the Medicare program, we
incorporated both factors in our measure of potential overservice.
Specifically, we identified areas that were both relatively high in
their level of utilization and relatively high in their growth in
utilization. We analyzed one of our access indicators, services per
beneficiary served, to measure potential overutilization. Using the
U.S. Census Bureau[Footnote 66] and OMB classifications, we divided
states into urban and rural areas and made additional distinctions
among urban areas, allowing us to classify counties into one of four
types of areas, as shown in table 9.[Footnote 67]
Table 9: Geographic Area Types for Utilization Analysis:
Geographic area: Metropolitan divisions;
Method of selection: Identified by the U.S. Census Bureau;
Number of areas: 32;
Percentage share of U.S. population: 26.
Geographic area: Large MSAs;
Method of selection: MSAs with 200,000 or more in population;
Number of areas: 174;
Percentage share of U.S. population: 49.
Geographic area: Small MSAs combined within states;
Method of selection: A combination of MSAs within the same state with
fewer than 200,000 residents;
Number of areas: 43;
Percentage share of U.S. population: 6.
Geographic area: Rural areas combined within states;
Method of selection: A combination of counties within the same state
that were outside of metropolitan divisions and MSAs;
Number of areas: 47;
Percentage share of U.S. population: 19.
Source: GAO analysis of U.S. Census Bureau data and Medicare Part B
claims and enrollment data.
Note: Area types are listed in descending order of population density.
[End of table]
We did not allow areas to cross state lines, so a metropolitan division
or MSA that crossed state lines was subdivided into separate areas for
each state. We examined a total of 296 areas, ranking them by their
level of utilization in 2000 and their change in utilization from 2000
to 2008. To determine an area's utilization status, we designated areas
in the top half of both measures as "potentially overserved" and the
rest as "other" areas. (See table 10.) This method resulted in 72 of
the 296 areas being designated as potentially overserved.[Footnote 68]
Table 10: Distribution of Geographic Areas by Ranking:
Ranking by change in the number of services per beneficiary served,
2000 to 2008:
Ranking by number of services per beneficiary served, 2000: Top half;
Top half: 72;
Bottom half: 76;
Total: 148.
Ranking by number of services per beneficiary served, 2000: Bottom
half;
Top half: 76;
Bottom half: 72;
Total: 148.
Ranking by number of services per beneficiary served, 2000: Total;
Top half: 148;
Bottom half: 148;
Total: 296.
Source: GAO analysis of U.S. Census Bureau data and Medicare Part B
claims data for April 2000 and April 2008.
[End of table]
To describe characteristics that distinguish potentially overserved
areas from other areas in the nation, we reviewed literature to
identify characteristics that could drive the use of physician
services.[Footnote 69] Using the most recently available data sources,
we constructed several area-level characteristics and compared them
between potentially overserved areas and all other areas. Specifically
we compared various demographic characteristics and compared the
capacity to provide health care services--both of which are factors
that could drive the use of physician services. We also compared
beneficiary satisfaction with their health care and the types of
physician services provided in the two types of areas. We examined the
provision of physician services broadly. However, our review of
clinical and economic studies in the literature suggested that certain
services might be or might not be prone to overuse and thus we also
compared the utilization of these services for both potentially
overserved and other areas. We obtained demographic data on mortality,
race, and education as well as data on health services capacity from
the Area Resource File (ARF), a national county-level health resource
information database produced by the Health Resources and Services
Administration of the Department of Health and Human Services;
population and income data from the U.S. Census Bureau; beneficiary age
and enrollment data from the Denominator file; and risk score data from
the CMS Medicare Advantage rate calculation data for 2009.[Footnote 70]
We obtained data on beneficiary perceptions and satisfaction with care
from the 2008 CAHPS survey. We used Medicare Part B claims to obtain
physician services utilization data.
As part of our analysis we found that potentially overserved areas were
more likely to be urban--that is, have greater population density--than
other areas. Therefore, when comparing various characteristics of
potentially overserved areas and other areas, we accounted for this
difference in population density by weighting the data from other areas
to reflect the same proportion of urbanization found in potentially
overserved areas.
We also analyzed the utilization of specific types of physician
services in potentially overserved and other areas. This analysis was
based on the Berenson-Eggers Type of Service (BETOS) code assigned to
each physician service in the Part B claims data. According to CMS, the
BETOS coding system consists of readily understood clinical categories,
is stable over time, and is relatively immune to minor changes in
technology or practice patterns. We compared the number of services per
1,000 Medicare FFS beneficiaries in potentially overserved and other
areas for selected service categories.[Footnote 71] We collapsed data
on other services and procedures into summary categories.
Data Reliability and Limitations:
We took several steps to ensure that the CAHPS, Medicare claims and
enrollment, U.S. Census Bureau, and ARF data were sufficiently reliable
for our analysis. For the CAHPS survey data, we examined the accuracy
and completeness of the data by testing for implausible values and
internal consistency and reviewed relevant documentation.[Footnote 72]
In addition, we interviewed experts at CMS about whether the CAHPS data
could appropriately be used as we intended. We concluded that the data
were sufficiently reliable for the purpose of this analysis. Our
analysis of the proportion of beneficiaries reporting major
difficulties accessing physician services was limited to beneficiaries
who needed an appointment for either routine or specialist care; it
does not refer to the entire population of Medicare beneficiaries.
Medicare claims data, which are used by the Medicare program as a
record of payments made to health care providers, are closely monitored
by both CMS and the Medicare carriers--contractors that process,
review, and pay claims for Part B-covered services. The data are
subject to various internal controls, including checks and edits
performed by the carriers before claims are submitted to CMS for
payment approval. Although we did not review these internal controls,
we did assess the reliability of the NCH data. First, we reviewed
existing information about the data, including the data dictionary and
file layouts. We also interviewed knowledgeable CMS officials about the
data. We examined the data files for obvious errors, missing values,
values outside of expected ranges, and dates outside of expected time
frames. We found the data to be sufficiently reliable for the purposes
of this report. We assessed the reliability of the U.S. Census Bureau
and ARF data by reviewing relevant documentation and examining the data
for obvious errors.
We conducted this performance audit from May 2008 through August 2009
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
[End of section]
Appendix II: Average Utilization Values by Geographic Area Type:
We classified geographic areas of the country by type of area and
utilization status. Our measure of utilization--services per
beneficiary served--is based on Medicare claims data for services
performed in the first 28 days of April 2000 and April 2008. An area
was designated as potentially overserved if it was in both the top half
of all areas in number of services per beneficiary served in 2000 and
in the top half of the growth rate in services per beneficiary served
from 2000 to 2008. Table 11 presents information, by geographic area
type and utilization status, on the average number of services per
beneficiary in 2000 and 2008, and the average change in the number of
services per beneficiary from 2000 to 2008.
Table 11: Average Utilization by Geographic Area Type:
Geographic area type[A]: Metropolitan divisions;
Utilization status: Potentially overserved areas: 15;
Utilization status: Other areas: 17;
Average number services per beneficiary served, 2000: Potentially
overserved areas: 3.84;
Average number services per beneficiary served, 2000: Other areas:
3.52;
Average number of services per beneficiary served, 2008: Potentially
overserved areas: 4.65;
Average number of services per beneficiary served, 2008: Other areas:
3.93;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Potentially overserved areas: 21.02;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Other areas: 12.03.
Geographic area type[A]: Large MSAs;
Utilization status: Potentially overserved areas: 47;
Utilization status: Other areas: 127;
Average number services per beneficiary served, 2000: Potentially
overserved areas: 3.54;
Average number services per beneficiary served, 2000: Other areas:
3.25;
Average number of services per beneficiary served, 2008: Potentially
overserved areas: 4.15;
Average number of services per beneficiary served, 2008: Other areas:
3.66;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Potentially overserved areas: 17.16;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Other areas: 13.07.
Geographic area type[A]: Small MSA areas;
Utilization status: Potentially overserved areas: 5;
Utilization status: Other areas: 38;
Average number services per beneficiary served, 2000: Potentially
overserved areas: 3.42;
Average number services per beneficiary served, 2000: Other areas:
3.25;
Average number of services per beneficiary served, 2008: Potentially
overserved areas: 3.97;
Average number of services per beneficiary served, 2008: Other areas:
3.61;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Potentially overserved areas: 16.15;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Other areas: 11.19.
Geographic area type[A]: Rural areas;
Utilization status: Potentially overserved areas: 5;
Utilization status: Other areas: 42;
Average number services per beneficiary served, 2000: Potentially
overserved areas: 3.36;
Average number services per beneficiary served, 2000: Other areas:
3.12;
Average number of services per beneficiary served, 2008: Potentially
overserved areas: 3.86;
Average number of services per beneficiary served, 2008: Other areas:
3.46;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Potentially overserved areas: 14.69;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Other areas: 11.12.
Geographic area type[A]: All areas;
Utilization status: Potentially overserved areas: 72;
Utilization status: Other areas: 224;
Average number services per beneficiary served, 2000: Potentially
overserved areas: 3.58;
Average number services per beneficiary served, 2000: Other areas:
3.24;
Average number of services per beneficiary served, 2008: Potentially
overserved areas: 4.22;
Average number of services per beneficiary served, 2008: Other areas:
3.64;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Potentially overserved areas: 17.72;
Average percentage change in services per beneficiary served, 2000 to
2008[B]: Other areas: 12.31.
Source: GAO analysis of U.S. Census Bureau data and Medicare Part B
claims and enrollment data for 2000 and 2008 from CMS.
[A] Counties were mapped to metropolitan divisions based on U.S. Census
Bureau designations. Nonrural counties outside of metropolitan
divisions were mapped to MSAs based on U.S. Census Bureau and OMB
designations. Small MSA areas are MSAs with fewer than 200,000 in
population grouped together within each state. Rural areas include all
rural counties within a state.
[B] The percentages presented in this table represent the average
percentages of individual areas within each geographic area type.
[End of table]
[End of section]
Appendix III: Utilization Status of Geographic Areas:
We identified potentially overserved areas of the country by
classifying U.S. counties into one of four types of geographic areas:
metropolitan divisions, large MSAs, small MSA areas, and rural areas.
This classification process yielded 296 areas across the United States.
We measured utilization in each of these areas by examining the number
of services per beneficiary who received services in April 2000 and
April 2008, and ranked them by their level of utilization in 2000 and
changes in utilization from 2000 to 2008. To determine an area's
utilization status, we designated areas in the top half of both
measures as potentially overserved areas and designated the rest as
other areas. Across all areas, the median number of services per
beneficiary served was 3.28 in 2000 and 3.71 in 2008. The median
percentage change in services per beneficiary served from 2000 to 2008
was 13.7. (See table 12.)
Table 12: Utilization Status of Geographic Areas:
State: Alabama;
Area name: Birmingham;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 975,560;
Services per beneficiary served, 2000: 3.38;
Services per beneficiary served, 2008: 3.91;
Percentage change in services per beneficiary served, 2000 to 2008:
15.8.
State: Alabama;
Area name: Huntsville;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 386,632;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
17.0.
State: Alabama;
Area name: Mobile;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 576,175;
Services per beneficiary served, 2000: 3.59;
Services per beneficiary served, 2008: 4.06;
Percentage change in services per beneficiary served, 2000 to 2008:
13.2.
State: Alabama;
Area name: Montgomery;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 353,276;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
State: Alabama;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 1,012,674;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
12.5.
State: Alabama;
Area name: Rural counties;
Status[A]: Potentially overserved area;
Type of area[B]: Rural areas;
Population, 2007: 1,323,534;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
14.4.
State: Alaska;
Area name: Anchorage;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 279,671;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.49;
Percentage change in services per beneficiary served, 2000 to 2008:
5.6.
State: Alaska;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 403,807;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.39;
Percentage change in services per beneficiary served, 2000 to 2008:
2.8.
State: Arizona;
Area name: Phoenix-Mesa;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 4,179,427;
Services per beneficiary served, 2000: 3.60;
Services per beneficiary served, 2008: 4.21;
Percentage change in services per beneficiary served, 2000 to 2008:
16.9.
State: Arizona;
Area name: Tucson;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 967,089;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.89;
Percentage change in services per beneficiary served, 2000 to 2008:
18.3.
State: Arizona;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 512,951;
Services per beneficiary served, 2000: 3.51;
Services per beneficiary served, 2008: 3.94;
Percentage change in services per beneficiary served, 2000 to 2008:
12.3.
State: Arizona;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 679,288;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
14.8.
State: Arkansas;
Area name: Fayetteville-Springdale-Rogers;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 397,399;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
11.7.
State: Arkansas;
Area name: Little Rock-North Little Rock;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 638,550;
Services per beneficiary served, 2000: 3.63;
Services per beneficiary served, 2008: 3.96;
Percentage change in services per beneficiary served, 2000 to 2008:
9.3.
State: Arkansas;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 446,100;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
10.8.
State: Arkansas;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,352,748;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
State: California;
Area name: Los Angeles-Long Beach-Glendale;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 9,878,554;
Services per beneficiary served, 2000: 4.48;
Services per beneficiary served, 2008: 4.63;
Percentage change in services per beneficiary served, 2000 to 2008:
3.4.
State: California;
Area name: Oakland-Fremont-Hayward;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,483,842;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
16.5.
State: California;
Area name: San Francisco-San Mateo-Redwood City;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,720,056;
Services per beneficiary served, 2000: 3.17;
Services per beneficiary served, 2008: 3.60;
Percentage change in services per beneficiary served, 2000 to 2008:
13.8.
State: California;
Area name: Santa Ana-Anaheim-Irvine;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,997,033;
Services per beneficiary served, 2000: 3.98;
Services per beneficiary served, 2008: 4.37;
Percentage change in services per beneficiary served, 2000 to 2008:
9.6.
State: California;
Area name: Bakersfield;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 790,710;
Services per beneficiary served, 2000: 3.67;
Services per beneficiary served, 2008: 4.24;
Percentage change in services per beneficiary served, 2000 to 2008:
15.4.
State: California;
Area name: Chico-Paradise;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 218,779;
Services per beneficiary served, 2000: 3.06;
Services per beneficiary served, 2008: 3.47;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
State: California;
Area name: Fresno;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,045,861;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
17.3.
State: California;
Area name: Merced;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 245,514;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.67;
Percentage change in services per beneficiary served, 2000 to 2008:
10.2.
State: California;
Area name: Modesto;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 511,263;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.61;
Percentage change in services per beneficiary served, 2000 to 2008:
16.2.
State: California;
Area name: Riverside County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 4,879,735;
Services per beneficiary served, 2000: 3.75;
Services per beneficiary served, 2008: 4.07;
Percentage change in services per beneficiary served, 2000 to 2008:
8.5.
State: California;
Area name: Sacramento-Yolo;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 2,091,120;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.46;
Percentage change in services per beneficiary served, 2000 to 2008:
8.7.
State: California;
Area name: Salinas;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 407,637;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
7.9.
State: California;
Area name: San Diego;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 2,974,859;
Services per beneficiary served, 2000: 3.56;
Services per beneficiary served, 2008: 3.98;
Percentage change in services per beneficiary served, 2000 to 2008:
12.0.
State: California;
Area name: San Luis Obispo-Atascadero-Paso Robles;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 262,436;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.49;
Percentage change in services per beneficiary served, 2000 to 2008:
12.7.
State: California;
Area name: Santa Barbara-Santa Maria-Lompoc;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 404,197;
Services per beneficiary served, 2000: 3.43;
Services per beneficiary served, 2008: 3.64;
Percentage change in services per beneficiary served, 2000 to 2008:
6.2.
State: California;
Area name: Santa Clara County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 3,006,322;
Services per beneficiary served, 2000: 3.07;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
State: California;
Area name: Stockton-Lodi;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 670,990;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.51;
Percentage change in services per beneficiary served, 2000 to 2008:
10.9.
State: California;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 343,565;
Services per beneficiary served, 2000: 3.39;
Services per beneficiary served, 2008: 3.68;
Percentage change in services per beneficiary served, 2000 to 2008:
8.6.
State: California;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,199,189;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.39;
Percentage change in services per beneficiary served, 2000 to 2008:
7.3.
State: Colorado;
Area name: Colorado Springs;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 587,272;
Services per beneficiary served, 2000: 3.17;
Services per beneficiary served, 2008: 3.68;
Percentage change in services per beneficiary served, 2000 to 2008:
16.1.
State: Colorado;
Area name: Denver-Boulder-Greeley;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 2,945,107;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.77;
Percentage change in services per beneficiary served, 2000 to 2008:
14.6.
State: Colorado;
Area name: Fort Collins-Loveland;
Status[A]: Other area; T
Type of area[B]: Large MSA;
Population, 2007: 287,574;
Services per beneficiary served, 2000: 3.02;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
16.3.
State: Colorado;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 293,620;
Services per beneficiary served, 2000: 2.92;
Services per beneficiary served, 2008: 3.28;
Percentage change in services per beneficiary served, 2000 to 2008:
12.3.
State: Colorado;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 747,942;
Services per beneficiary served, 2000: 2.92;
Services per beneficiary served, 2008: 3.28;
Percentage change in services per beneficiary served, 2000 to 2008:
12.4.
State: Connecticut;
Area name: Fairfield County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,928,782;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.95;
Percentage change in services per beneficiary served, 2000 to 2008:
20.6.
State: Connecticut;
Area name: Hartford;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,306,151;
Services per beneficiary served, 2000: 3.00;
Services per beneficiary served, 2008: 3.61;
Percentage change in services per beneficiary served, 2000 to 2008:
20.3.
State: Connecticut;
Area name: New London-Norwich;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 267,376;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.83;
Percentage change in services per beneficiary served, 2000 to 2008:
23.9.
State: Delaware;
Area name: Wilmington;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 528,218;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.97;
Percentage change in services per beneficiary served, 2000 to 2008:
21.5.
State: Delaware;
Area name: Small metropolitan areas;
Status[A]: Potentially overserved area;
Type of area[B]: Small MSA areas;
Population, 2007: 152,255;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
17.5.
State: Delaware;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 184,291;
Services per beneficiary served, 2000: 3.34;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
11.6.
State: District of Columbia;
Area name: Washington[C];
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 588,292;
Services per beneficiary served, 2000: 3.86;
Services per beneficiary served, 2008: 4.22;
Percentage change in services per beneficiary served, 2000 to 2008:
9.2.
State: Florida;
Area name: Fort Lauderdale-Pompano Beach-Deerfield Beach;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,759,591;
Services per beneficiary served, 2000: 4.24;
Services per beneficiary served, 2008: 5.13;
Percentage change in services per beneficiary served, 2000 to 2008:
21.1.
State: Florida;
Area name: Miami-Miami Beach-Kendall;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,387,170;
Services per beneficiary served, 2000: 4.53;
Services per beneficiary served, 2008: 5.15;
Percentage change in services per beneficiary served, 2000 to 2008:
13.7.
State: Florida;
Area name: West Palm Beach-Boca Raton-Boynton Beach;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,266,451;
Services per beneficiary served, 2000: 4.25;
Services per beneficiary served, 2008: 5.15;
Percentage change in services per beneficiary served, 2000 to 2008:
21.4.
State: Florida;
Area name: Daytona Beach;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 588,810;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 4.08;
Percentage change in services per beneficiary served, 2000 to 2008:
24.8.
State: Florida;
Area name: Fort Myers-Cape Coral;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 590,564;
Services per beneficiary served, 2000: 3.55;
Services per beneficiary served, 2008: 4.48;
Percentage change in services per beneficiary served, 2000 to 2008:
26.1.
State: Florida;
Area name: Fort Pierce-Port St. Lucie;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 400,121;
Services per beneficiary served, 2000: 3.81;
Services per beneficiary served, 2008: 4.56;
Percentage change in services per beneficiary served, 2000 to 2008:
19.4.
State: Florida; Area name: Gainesville;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 240,082;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 3.92;
Percentage change in services per beneficiary served, 2000 to 2008:
17.1.
State: Florida;
Area name: Jacksonville;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 1,275,078;
Services per beneficiary served, 2000: 3.83;
Services per beneficiary served, 2008: 4.59;
Percentage change in services per beneficiary served, 2000 to 2008:
20.0.
State: Florida;
Area name: Lakeland-Winter Haven;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 574,746;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 4.14;
Percentage change in services per beneficiary served, 2000 to 2008:
19.3.
State: Florida;
Area name: Melbourne-Titusville-Palm Bay;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 536,161;
Services per beneficiary served, 2000: 3.66;
Services per beneficiary served, 2008: 4.43;
Percentage change in services per beneficiary served, 2000 to 2008:
21.1.
State: Florida;
Area name: Naples;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 315,839;
Services per beneficiary served, 2000: 3.88;
Services per beneficiary served, 2008: 4.63;
Percentage change in services per beneficiary served, 2000 to 2008:
19.4.
State: Florida;
Area name: Ocala;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 324,857;
Services per beneficiary served, 2000: 3.45;
Services per beneficiary served, 2008: 4.02;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
State: Florida;
Area name: Orlando;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 2,032,496;
Services per beneficiary served, 2000: 3.65;
Services per beneficiary served, 2008: 4.32;
Percentage change in services per beneficiary served, 2000 to 2008:
18.3.
State: Florida;
Area name: Pensacola;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 453,451;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
14.9.
State: Florida;
Area name: Sarasota-Bradenton;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 687,181;
Services per beneficiary served, 2000: 3.61;
Services per beneficiary served, 2008: 4.33;
Percentage change in services per beneficiary served, 2000 to 2008:
20.2.
State: Florida;
Area name: Tallahassee;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 308,142;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.62;
Percentage change in services per beneficiary served, 2000 to 2008:
17.6.
State: Florida;
Area name: Tampa-St. Petersburg-Clearwater;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 2,723,949;
Services per beneficiary served, 2000: 3.75;
Services per beneficiary served, 2008: 4.47;
Percentage change in services per beneficiary served, 2000 to 2008:
19.2.
State: Florida;
Area name: Small metropolitan areas;
Status[A]: Potentially overserved area;
Type of area[B]: Small MSA areas;
Population, 2007: 498,297;
Services per beneficiary served, 2000: 3.69;
Services per beneficiary served, 2008: 4.34;
Percentage change in services per beneficiary served, 2000 to 2008:
17.9.
State: Florida;
Area name: Rural counties;
Status[A]: Potentially overserved area;
Type of area[B]: Rural areas;
Population, 2007: 1,288,257;
Services per beneficiary served, 2000: 3.60;
Services per beneficiary served, 2008: 4.18;
Percentage change in services per beneficiary served, 2000 to 2008:
16.1.
State: Georgia;
Area name: Atlanta;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 5,122,983;
Services per beneficiary served, 2000: 3.31;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
17.4.
State: Georgia;
Area name: Augusta[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 328,023;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.44;
Percentage change in services per beneficiary served, 2000 to 2008:
5.6.
State: Georgia;
Area name: Columbus;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 225,549;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
14.5.
State: Georgia;
Area name: Macon;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 348,906;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 4.00;
Percentage change in services per beneficiary served, 2000 to 2008:
23.5.
State: Georgia;
Area name: Savannah;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 329,329;
Services per beneficiary served, 2000: 3.52;
Services per beneficiary served, 2008: 3.92;
Percentage change in services per beneficiary served, 2000 to 2008:
11.6.
State: Georgia;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 445,078;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.60;
Percentage change in services per beneficiary served, 2000 to 2008:
8.1.
State: Georgia;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 2,744,882;
Services per beneficiary served, 2000: 3.19;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
12.7.
State: Hawaii;
Area name: Honolulu;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 905,601;
Services per beneficiary served, 2000: 3.04;
Services per beneficiary served, 2008: 3.29;
Percentage change in services per beneficiary served, 2000 to 2008:
8.5.
State: Hawaii;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 377,668;
Services per beneficiary served, 2000: 2.93;
Services per beneficiary served, 2008: 3.12;
Percentage change in services per beneficiary served, 2000 to 2008:
6.6.
State: Idaho;
Area name: Boise City;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 552,787;
Services per beneficiary served, 2000: 2.90;
Services per beneficiary served, 2008: 3.23;
Percentage change in services per beneficiary served, 2000 to 2008:
11.6.
State: Idaho;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 79,925;
Services per beneficiary served, 2000: 2.72;
Services per beneficiary served, 2008: 2.99;
Percentage change in services per beneficiary served, 2000 to 2008:
9.6.
State: Idaho;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 866,690;
Services per beneficiary served, 2000: 2.91;
Services per beneficiary served, 2008: 3.14;
Percentage change in services per beneficiary served, 2000 to 2008:
7.7.
State: Illinois;
Area name: Chicago-Naperville-Joliet;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 7,952,540;
Services per beneficiary served, 2000: 3.71;
Services per beneficiary served, 2008: 4.48;
Percentage change in services per beneficiary served, 2000 to 2008:
20.7.
State: Illinois;
Area name: Lake County[C];
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 710,241;
Services per beneficiary served, 2000: 3.41;
Services per beneficiary served, 2008: 4.28;
Percentage change in services per beneficiary served, 2000 to 2008:
25.6.
State: Illinois;
Area name: Madison County[C];
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 619,940;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
13.9.
State: Illinois;
Area name: Peoria-Pekin;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 352,164;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.63;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
State: Illinois;
Area name: Rockford;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 407,301;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
22.2.
State: Illinois;
Area name: Springfield;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 206,588;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 4.01;
Percentage change in services per beneficiary served, 2000 to 2008:
19.7.
State: Illinois;
Area name: Small metropolitan areas;
Status[A]: Potentially overserved area;
Type of area[B]: Small MSA areas;
Population, 2007: 770,889;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.83;
Percentage change in services per beneficiary served, 2000 to 2008:
16.2.
State: Illinois;
Area name: Rural counties;
Status[A]: Potentially overserved;
Type of area[B]: Rural areas;
Population, 2007: 1,832,885;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
13.9.
State: Indiana;
Area name: Gary;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 652,682;
Services per beneficiary served, 2000: 3.56;
Services per beneficiary served, 2008: 4.45;
Percentage change in services per beneficiary served, 2000 to 2008:
24.7.
State: Indiana;
Area name: Clark County[C];
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 238,588;
Services per beneficiary served, 2000: 3.43;
Services per beneficiary served, 2008: 4.01;
Percentage change in services per beneficiary served, 2000 to 2008:
16.9.
State: Indiana;
Area name: Evansville[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 257,777;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.70;
Percentage change in services per beneficiary served, 2000 to 2008:
21.3.
State: Indiana;
Area name: Fort Wayne;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 523,253;
Services per beneficiary served, 2000: 2.99;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
19.2.
State: Indiana;
Area name: Indianapolis;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,774,665;
Services per beneficiary served, 2000: 3.19;
Services per beneficiary served, 2008: 3.64;
Percentage change in services per beneficiary served, 2000 to 2008:
14.4.
State: Indiana;
Area name: South Bend;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 266,088;
Services per beneficiary served, 2000: 2.98;
Services per beneficiary served, 2008: 3.64;
Percentage change in services per beneficiary served, 2000 to 2008:
21.9.
State: Indiana;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 942,519;
Services per beneficiary served, 2000: 3.14;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
16.8.
State: Indiana;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,689,717;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.49;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
State: Iowa;
Area name: Cedar Rapids;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 205,836;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.40;
Percentage change in services per beneficiary served, 2000 to 2008:
10.1.
State: Iowa;
Area name: Des Moines;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 520,130;
Services per beneficiary served, 2000: 3.43;
Services per beneficiary served, 2008: 3.67;
Percentage change in services per beneficiary served, 2000 to 2008:
6.9.
State: Iowa;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 699,880;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
10.4.
State: Iowa;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,562,200;
Services per beneficiary served, 2000: 3.06;
Services per beneficiary served, 2008: 3.35;
Percentage change in services per beneficiary served, 2000 to 2008:
9.6.
State: Kansas;
Area name: Johnson County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 784,956;
Services per beneficiary served, 2000: 3.60;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
8.5.
State: Kansas;
Area name: Wichita;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 572,564;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
12.4.
State: Kansas;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 286,964;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.45;
Percentage change in services per beneficiary served, 2000 to 2008:
14.0.
State: Kansas;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,131,513;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.51;
Percentage change in services per beneficiary served, 2000 to 2008:
11.4.
State: Kentucky;
Area name: Kenton County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 404,246;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 4.13;
Percentage change in services per beneficiary served, 2000 to 2008:
27.0.
State: Kentucky;
Area name: Lexington;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 528,276;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.67;
Percentage change in services per beneficiary served, 2000 to 2008:
18.5.
State: Kentucky;
Area name: Louisville[C];
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 839,130;
Services per beneficiary served, 2000: 3.65;
Services per beneficiary served, 2008: 4.20;
Percentage change in services per beneficiary served, 2000 to 2008:
15.1.
State: Kentucky;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 333,095;
Services per beneficiary served, 2000: 3.52;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
10.8.
State: Kentucky;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 2,136,727;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
13.8.
State: Louisiana;
Area name: Baton Rouge;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 668,578;
Services per beneficiary served, 2000: 3.76;
Services per beneficiary served, 2008: 3.97;
Percentage change in services per beneficiary served, 2000 to 2008:
5.7.
State: Louisiana;
Area name: Houma;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 201,137;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
State: Louisiana;
Area name: Lafayette;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 407,814;
Services per beneficiary served, 2000: 3.46;
Services per beneficiary served, 2008: 3.89;
Percentage change in services per beneficiary served, 2000 to 2008:
12.5.
State: Louisiana;
Area name: New Orleans;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,051,941;
Services per beneficiary served, 2000: 3.75;
Services per beneficiary served, 2008: 4.20;
Percentage change in services per beneficiary served, 2000 to 2008:
12.1.
State: Louisiana;
Area name: Shreveport-Bossier City;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 402,238;
Services per beneficiary served, 2000: 3.58;
Services per beneficiary served, 2008: 3.98;
Percentage change in services per beneficiary served, 2000 to 2008:
11.3.
State: Louisiana;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 464,093;
Services per beneficiary served, 2000: 3.65;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
6.7.
State: Louisiana;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,097,403;
Services per beneficiary served, 2000: 3.54;
Services per beneficiary served, 2008: 4.01;
Percentage change in services per beneficiary served, 2000 to 2008:
13.1.
State: Maine;
Area name: Portland;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 275,374;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.34;
Percentage change in services per beneficiary served, 2000 to 2008:
5.8.
State: Maine;
Area name: York County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 201,341;
Services per beneficiary served, 2000: 3.07;
Services per beneficiary served, 2008: 3.42;
Percentage change in services per beneficiary served, 2000 to 2008:
11.3.
State: Maine;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 330,497;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.25;
Percentage change in services per beneficiary served, 2000 to 2008:
3.8.
State: Maine;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 509,995;
Services per beneficiary served, 2000: 2.97;
Services per beneficiary served, 2008: 3.18;
Percentage change in services per beneficiary served, 2000 to 2008:
7.0.
State: Maryland;
Area name: Bethesda-Frederick-Gaithersburg;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,155,518;
Services per beneficiary served, 2000: 3.59;
Services per beneficiary served, 2008: 4.06;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
State: Maryland;
Area name: Prince George's County[C];
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,057,437;
Services per beneficiary served, 2000: 3.80;
Services per beneficiary served, 2008: 4.08;
Percentage change in services per beneficiary served, 2000 to 2008:
7.5.
State: Maryland;
Area name: Baltimore[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 2,813,169;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
State: Maryland;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 172,289;
Services per beneficiary served, 2000: 3.48;
Services per beneficiary served, 2008: 3.84;
Percentage change in services per beneficiary served, 2000 to 2008:
10.4.
State: Maryland;
Area name: Rural counties;
Status[A]: Potentially overserved area;
Type of area[B]: Rural areas;
Population, 2007: 419,931;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
14.5.
State: Massachusetts;
Area name: Boston-Quincy;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,858,216;
Services per beneficiary served, 2000: 3.49;
Services per beneficiary served, 2008: 3.83;
Percentage change in services per beneficiary served, 2000 to 2008:
9.8.
State: Massachusetts;
Area name: Essex;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 733,101;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.80;
Percentage change in services per beneficiary served, 2000 to 2008:
12.8.
State: Massachusetts;
Area name: Newton-Framingham[C];
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,473,416;
Services per beneficiary served, 2000: 3.43;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
10.2.
State: Massachusetts;
Area name: Barnstable-Yarmouth;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 222,175;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.64;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
State: Massachusetts;
Area name: Springfield;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 682,657;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.50;
Percentage change in services per beneficiary served, 2000 to 2008:
12.3.
State: Massachusetts;
Area name: Worcester County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,324,376;
Services per beneficiary served, 2000: 3.31;
Services per beneficiary served, 2008: 3.70;
Percentage change in services per beneficiary served, 2000 to 2008:
11.7.
State: Massachusetts;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 129,798;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
18.4.
State: Massachusetts;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 26,016;
Services per beneficiary served, 2000: 3.07;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
11.6.
State: Michigan;
Area name: Detroit-Livonia-Dearborn;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,985,101;
Services per beneficiary served, 2000: 3.87;
Services per beneficiary served, 2008: 4.76;
Percentage change in services per beneficiary served, 2000 to 2008:
23.1.
State: Michigan;
Area name: Warren-Troy-Farmington Hills;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,482,491;
Services per beneficiary served, 2000: 3.82;
Services per beneficiary served, 2008: 4.70;
Percentage change in services per beneficiary served, 2000 to 2008:
23.2.
State: Michigan;
Area name: Ann Arbor-Flint[C];
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 1,039,569;
Services per beneficiary served, 2000: 3.49;
Services per beneficiary served, 2008: 4.19;
Percentage change in services per beneficiary served, 2000 to 2008:
20.0.
State: Michigan;
Area name: Grand Rapids-Muskegon-Holland;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,150,683;
Services per beneficiary served, 2000: 2.94;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
19.5.
State: Michigan;
Area name: Kalamazoo-Battle Creek;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 459,879;
Services per beneficiary served, 2000: 3.00;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
18.5.
State: Michigan;
Area name: Lansing-East Lansing;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 456,440;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.96;
Percentage change in services per beneficiary served, 2000 to 2008:
17.6.
State: Michigan;
Area name: Saginaw-Bay City-Midland;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 392,603;
Services per beneficiary served, 2000: 3.45;
Services per beneficiary served, 2008: 4.01;
Percentage change in services per beneficiary served, 2000 to 2008:
16.1.
State: Michigan;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 322,595;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.67;
Percentage change in services per beneficiary served, 2000 to 2008:
16.2.
State: Michigan;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,782,461;
Services per beneficiary served, 2000: 3.14;
Services per beneficiary served, 2008: 3.68;
Percentage change in services per beneficiary served, 2000 to 2008:
17.1.
State: Minnesota;
Area name: Minneapolis-St. Paul;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 3,087,504;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.61;
Percentage change in services per beneficiary served, 2000 to 2008:
15.4.
State: Minnesota;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 627,054;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.48;
Percentage change in services per beneficiary served, 2000 to 2008:
10.4.
State: Minnesota;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,483,063;
Services per beneficiary served, 2000: 2.94;
Services per beneficiary served, 2008: 3.37;
Percentage change in services per beneficiary served, 2000 to 2008:
14.6.
State: Mississippi;
Area name: Biloxi-Gulfport-Pascagoula;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 345,890;
Services per beneficiary served, 2000: 3.80;
Services per beneficiary served, 2008: 3.92;
Percentage change in services per beneficiary served, 2000 to 2008:
3.1.
State: Mississippi;
Area name: Jackson;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 476,906;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.77;
Percentage change in services per beneficiary served, 2000 to 2008:
14.5.
State: Mississippi;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 275,332;
Services per beneficiary served, 2000: 3.65;
Services per beneficiary served, 2008: 4.01;
Percentage change in services per beneficiary served, 2000 to 2008:
9.8.
State: Mississippi;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,820,657;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.67;
Percentage change in services per beneficiary served, 2000 to 2008:
10.2.
State: Missouri;
Area name: Kansas City[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,137,909;
Services per beneficiary served, 2000: 3.49;
Services per beneficiary served, 2008: 3.91;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
State: Missouri;
Area name: Springfield;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 372,973;
Services per beneficiary served, 2000: 2.88;
Services per beneficiary served, 2008: 3.29;
Percentage change in services per beneficiary served, 2000 to 2008:
14.1.
State: Missouri;
Area name: St. Louis[C];
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 2,087,945;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 3.96;
Percentage change in services per beneficiary served, 2000 to 2008:
18.0.
State: Missouri;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 427,062;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
15.6.
State: Missouri;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,852,526;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
14.1.
State: Montana;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 327,361;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.47;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
State: Montana;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 630,500;
Services per beneficiary served, 2000: 3.02;
Services per beneficiary served, 2008: 3.25;
Percentage change in services per beneficiary served, 2000 to 2008:
7.6.
State: Nebraska;
Area name: Lincoln;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 275,665;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.77;
Percentage change in services per beneficiary served, 2000 to 2008:
20.4.
State: Nebraska;
Area name: Omaha;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 689,708;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.96;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
State: Nebraska;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 20,312;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.23;
Percentage change in services per beneficiary served, 2000 to 2008: -
4.2.
State: Nebraska;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 788,886;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.47;
Percentage change in services per beneficiary served, 2000 to 2008:
13.7.
State: Nevada;
Area name: Las Vegas;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,880,449;
Services per beneficiary served, 2000: 4.09;
Services per beneficiary served, 2008: 4.63;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
State: Nevada;
Area name: Reno;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 406,079;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.63;
Percentage change in services per beneficiary served, 2000 to 2008:
13.1.
State: Nevada;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 278,854;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.41;
Percentage change in services per beneficiary served, 2000 to 2008:
10.0.
State: New Hampshire;
Area name: Rockingham County-Strafford County;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 418,124;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.61;
Percentage change in services per beneficiary served, 2000 to 2008:
16.9.
State: New Hampshire;
Area name: Hillsborough County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 550,576;
Services per beneficiary served, 2000: 3.04;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
13.0.
State: New Hampshire;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 347,128;
Services per beneficiary served, 2000: 2.85;
Services per beneficiary served, 2008: 3.20;
Percentage change in services per beneficiary served, 2000 to 2008:
12.5.
State: New Jersey;
Area name: Camden;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,246,339;
Services per beneficiary served, 2000: 3.66;
Services per beneficiary served, 2008: 4.15;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
State: New Jersey;
Area name: Edison-New Brunswick;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,319,704;
Services per beneficiary served, 2000: 3.72;
Services per beneficiary served, 2008: 4.46;
Percentage change in services per beneficiary served, 2000 to 2008:
20.0.
State: New Jersey;
Area name: Newark-Union;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,070,046;
Services per beneficiary served, 2000: 3.70;
Services per beneficiary served, 2008: 4.47;
Percentage change in services per beneficiary served, 2000 to 2008:
20.8.
State: New Jersey; Area name: Wayne[C];
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,986,019;
Services per beneficiary served, 2000: 3.84;
Services per beneficiary served, 2008: 4.61;
Percentage change in services per beneficiary served, 2000 to 2008:
20.0.
State: New Jersey;
Area name: Atlantic County[C];
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 522,610;
Services per beneficiary served, 2000: 3.71;
Services per beneficiary served, 2008: 4.24;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
State: New Jersey;
Area name: Mercer County[C];
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 475,186;
Services per beneficiary served, 2000: 3.70;
Services per beneficiary served, 2008: 4.39;
Percentage change in services per beneficiary served, 2000 to 2008:
18.7.
State: New Jersey;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 66,016;
Services per beneficiary served, 2000: 3.73;
Services per beneficiary served, 2008: 4.04;
Percentage change in services per beneficiary served, 2000 to 2008:
8.2.
State: New Mexico;
Area name: Albuquerque;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 818,522;
Services per beneficiary served, 2000: 3.02;
Services per beneficiary served, 2008: 3.23;
Percentage change in services per beneficiary served, 2000 to 2008:
6.7.
State: New Mexico;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 360,304;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.41;
Percentage change in services per beneficiary served, 2000 to 2008:
10.4.
State: New Mexico;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 791,089;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.30;
Percentage change in services per beneficiary served, 2000 to 2008:
6.9.
State: New York;
Area name: Nassau-Suffolk;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,759,762;
Services per beneficiary served, 2000: 3.86;
Services per beneficiary served, 2008: 4.76;
Percentage change in services per beneficiary served, 2000 to 2008:
23.2.
State: New York;
Area name: New York-White Plains[C];
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 9,621,824;
Services per beneficiary served, 2000: 3.91;
Services per beneficiary served, 2008: 4.97;
Percentage change in services per beneficiary served, 2000 to 2008:
27.0.
State: New York;
Area name: Albany-Schenectady-Troy;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 902,053;
Services per beneficiary served, 2000: 3.34;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
14.4.
State: New York;
Area name: Binghamton;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 246,426;
Services per beneficiary served, 2000: 3.17;
Services per beneficiary served, 2008: 3.45;
Percentage change in services per beneficiary served, 2000 to 2008:
9.0.
State: New York;
Area name: Buffalo-Niagara Falls;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,128,183;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
13.5.
State: New York;
Area name: Orange County;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 669,915;
Services per beneficiary served, 2000: 3.43;
Services per beneficiary served, 2008: 4.20;
Percentage change in services per beneficiary served, 2000 to 2008:
22.7.
State: New York;
Area name: Rochester;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,088,617;
Services per beneficiary served, 2000: 2.87;
Services per beneficiary served, 2008: 3.36;
Percentage change in services per beneficiary served, 2000 to 2008:
17.0.
State: New York;
Area name: Syracuse;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 725,359;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.60;
Percentage change in services per beneficiary served, 2000 to 2008:
9.7.
State: New York;
Area name: Utica-Rome;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 294,862;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
State: New York;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 350,846;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
State: New York;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,509,882;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
13.9.
State: North Carolina;
Area name: Asheville;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 247,080;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.28;
Percentage change in services per beneficiary served, 2000 to 2008:
4.7.
State: North Carolina;
Area name: Charlotte-Gastonia[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,628,028;
Services per beneficiary served, 2000: 3.20;
Services per beneficiary served, 2008: 3.67;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
State: North Carolina;
Area name: Fayetteville;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 306,518;
Services per beneficiary served, 2000: 2.96;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
24.7.
State: North Carolina;
Area name: Greensboro-Winston Salem-High Point;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,371,125;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
State: North Carolina;
Area name: Hickory-Morganton-Lenoir;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 360,471;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.46;
Percentage change in services per beneficiary served, 2000 to 2008:
13.5.
State: North Carolina;
Area name: Raleigh-Durham-Chapel Hill;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,489,897;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.54;
Percentage change in services per beneficiary served, 2000 to 2008:
16.1.
State: North Carolina;
Area name: Wilmington;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 289,646;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
5.5.
State: North Carolina;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 657,154;
Services per beneficiary served, 2000: 3.19;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
12.0.
State: North Carolina;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 2,711,113;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
State: North Dakota;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 307,807;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.40;
Percentage change in services per beneficiary served, 2000 to 2008:
7.9.
State: North Dakota;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 331,908;
Services per beneficiary served, 2000: 2.98;
Services per beneficiary served, 2008: 3.30;
Percentage change in services per beneficiary served, 2000 to 2008:
10.7.
State: Ohio;
Area name: Canton-Massillon;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 407,180;
Services per beneficiary served, 2000: 3.39;
Services per beneficiary served, 2008: 3.84;
Percentage change in services per beneficiary served, 2000 to 2008:
13.1.
State: Ohio;
Area name: Cincinnati[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,642,093;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
20.9.
State: Ohio;
Area name: Cleveland-Akron;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 2,896,968;
Services per beneficiary served, 2000: 3.42;
Services per beneficiary served, 2008: 4.08;
Percentage change in services per beneficiary served, 2000 to 2008:
19.6.
State: Ohio;
Area name: Columbus;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,672,583;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
State: Ohio;
Area name: Dayton-Springfield;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 934,275;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.93;
Percentage change in services per beneficiary served, 2000 to 2008:
21.1.
State: Ohio;
Area name: Toledo;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 609,871;
Services per beneficiary served, 2000: 3.56;
Services per beneficiary served, 2008: 4.07;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
State: Ohio;
Area name: Youngstown-Warren;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 562,593;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 4.17;
Percentage change in services per beneficiary served, 2000 to 2008:
19.1.
State: Ohio;
Area name: Small metropolitan areas;
Status[A]: Potentially overserved area;
Type of area[B]: Small MSA areas;
Population, 2007: 582,391;
Services per beneficiary served, 2000: 3.39;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
15.0.
State: Ohio;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 2,158,963;
Services per beneficiary served, 2000: 3.17;
Services per beneficiary served, 2008: 3.70;
Percentage change in services per beneficiary served, 2000 to 2008:
17.0.
State: Oklahoma;
Area name: Oklahoma City;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,179,140;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.62;
Percentage change in services per beneficiary served, 2000 to 2008:
8.9.
State: Oklahoma;
Area name: Tulsa;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 850,008;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
10.3.
State: Oklahoma;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 212,492;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.61;
Percentage change in services per beneficiary served, 2000 to 2008:
9.3.
State: Oklahoma;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,375,676;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.46;
Percentage change in services per beneficiary served, 2000 to 2008:
6.2.
State: Oregon;
Area name: Eugene-Springfield;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 343,591;
Services per beneficiary served, 2000: 2.84;
Services per beneficiary served, 2008: 3.21;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
State: Oregon;
Area name: Portland-Salem[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 2,133,034;
Services per beneficiary served, 2000: 2.95;
Services per beneficiary served, 2008: 3.36;
Percentage change in services per beneficiary served, 2000 to 2008:
13.9.
State: Oregon;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 280,723;
Services per beneficiary served, 2000: 2.91;
Services per beneficiary served, 2008: 3.34;
Percentage change in services per beneficiary served, 2000 to 2008:
15.0.
State: Oregon;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 990,107;
Services per beneficiary served, 2000: 2.89;
Services per beneficiary served, 2008: 3.16;
Percentage change in services per beneficiary served, 2000 to 2008:
9.4.
State: Pennsylvania;
Area name: Philadelphia;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 3,887,694;
Services per beneficiary served, 2000: 3.77;
Services per beneficiary served, 2008: 4.34;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
State: Pennsylvania;
Area name: Allentown-Bethlehem-Easton;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 694,107;
Services per beneficiary served, 2000: 3.44;
Services per beneficiary served, 2008: 3.92;
Percentage change in services per beneficiary served, 2000 to 2008:
14.0.
State: Pennsylvania;
Area name: Erie;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 279,092;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
17.0.
State: Pennsylvania;
Area name: Harrisburg-Lebanon-Carlisle;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 656,781;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
State: Pennsylvania;
Area name: Johnstown;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 222,856;
Services per beneficiary served, 2000: 3.31;
Services per beneficiary served, 2008: 3.95;
Percentage change in services per beneficiary served, 2000 to 2008:
19.6.
State: Pennsylvania;
Area name: Lancaster;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 498,465;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
14.1.
State: Pennsylvania;
Area name: Pittsburgh;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 2,286,653;
Services per beneficiary served, 2000: 3.79;
Services per beneficiary served, 2008: 4.45;
Percentage change in services per beneficiary served, 2000 to 2008:
17.2.
State: Pennsylvania;
Area name: Reading;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 401,955;
Services per beneficiary served, 2000: 3.19;
Services per beneficiary served, 2008: 3.83;
Percentage change in services per beneficiary served, 2000 to 2008:
20.0.
State: Pennsylvania;
Area name: Scranton-Wilkes-Barre-Hazleton;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 614,156;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 3.87;
Percentage change in services per beneficiary served, 2000 to 2008:
11.5.
State: Pennsylvania;
Area name: York;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 421,049;
Services per beneficiary served, 2000: 3.06;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
15.0.
State: Pennsylvania;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 562,438;
Services per beneficiary served, 2000: 3.39;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
7.9.
State: Pennsylvania;
Area name: Rural counties;
Status[A]: Potentially overserved area;
Type of area[B]: Rural areas;
Population, 2007: 1,907,546;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
14.5.
State: Rhode Island;
Area name: Providence-Warwick[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,057,832;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.73;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
State: South Carolina;
Area name: Charleston-North Charleston;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 630,100;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.67;
Percentage change in services per beneficiary served, 2000 to 2008:
13.0.
State: South Carolina;
Area name: Columbia;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 601,004;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.84;
Percentage change in services per beneficiary served, 2000 to 2008:
17.8.
State: South Carolina;
Area name: Greenville-Spartanburg-Anderson;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,053,776;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.50;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
State: South Carolina;
Area name: Myrtle Beach;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 249,925;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 3.73;
Percentage change in services per beneficiary served, 2000 to 2008:
7.6.
State: South Carolina;
Area name: York County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 208,827;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
19.8.
State: South Carolina;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 413,571;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.65;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
State: South Carolina;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,250,506;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.70;
Percentage change in services per beneficiary served, 2000 to 2008:
13.0.
State: South Dakota;
Area name: Sioux Falls;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 213,037;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
17.5.
State: South Dakota;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 96,280;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.30;
Percentage change in services per beneficiary served, 2000 to 2008:
2.8.
State: South Dakota;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 486,897;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.30;
Percentage change in services per beneficiary served, 2000 to 2008:
4.9.
State: Tennessee;
Area name: Chattanooga;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 358,306;
Services per beneficiary served, 2000: 3.45;
Services per beneficiary served, 2008: 3.79;
Percentage change in services per beneficiary served, 2000 to 2008:
10.0.
State: Tennessee;
Area name: Johnson City-Kingsport-Bristol;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 404,127;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
State: Tennessee;
Area name: Knoxville;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 765,052;
Services per beneficiary served, 2000: 3.39;
Services per beneficiary served, 2008: 3.77;
Percentage change in services per beneficiary served, 2000 to 2008:
11.3.
State: Tennessee;
Area name: Memphis;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 1,004,979;
Services per beneficiary served, 2000: 3.94;
Services per beneficiary served, 2008: 4.49;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
State: Tennessee;
Area name: Nashville;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 1,436,104;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
15.1.
State: Tennessee;
Area name: Small metropolitan areas;
Status[A]: Potentially overserved area;
Type of area[B]: Small MSA areas;
Population, 2007: 267,120;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
State: Tennessee;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,921,031;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.70;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
State: Texas;
Area name: Dallas-Plano-Irving;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 4,106,154;
Services per beneficiary served, 2000: 3.73;
Services per beneficiary served, 2008: 4.16;
Percentage change in services per beneficiary served, 2000 to 2008:
11.6.
State: Texas;
Area name: Fort Worth-Arlington;
Status[A]: Potentially overserved area;
Type of area[B]: Metropolitan division;
Population, 2007: 1,975,919;
Services per beneficiary served, 2000: 3.45;
Services per beneficiary served, 2008: 3.98;
Percentage change in services per beneficiary served, 2000 to 2008:
15.5.
State: Texas;
Area name: Amarillo;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 233,811;
Services per beneficiary served, 2000: 3.58;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
9.0.
State: Texas;
Area name: Austin-San Marcos;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,598,161;
Services per beneficiary served, 2000: 3.52;
Services per beneficiary served, 2008: 3.87;
Percentage change in services per beneficiary served, 2000 to 2008:
9.8.
State: Texas;
Area name: Beaumont-Port Arthur;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 376,241;
Services per beneficiary served, 2000: 3.76;
Services per beneficiary served, 2008: 4.24;
Percentage change in services per beneficiary served, 2000 to 2008:
12.8.
State: Texas;
Area name: Brownsville-Harlingen-San Benito;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 387,210;
Services per beneficiary served, 2000: 4.10;
Services per beneficiary served, 2008: 4.66;
Percentage change in services per beneficiary served, 2000 to 2008:
13.8.
State: Texas;
Area name: Corpus Christi;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 389,655;
Services per beneficiary served, 2000: 3.76;
Services per beneficiary served, 2008: 4.29;
Percentage change in services per beneficiary served, 2000 to 2008:
13.9.
State: Texas;
Area name: El Paso;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 734,669;
Services per beneficiary served, 2000: 3.64;
Services per beneficiary served, 2008: 3.89;
Percentage change in services per beneficiary served, 2000 to 2008:
6.7.
State: Texas;
Area name: Houston-Galveston-Brazoria;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 5,576,673;
Services per beneficiary served, 2000: 4.85;
Services per beneficiary served, 2008: 4.80;
Percentage change in services per beneficiary served, 2000 to 2008:
-1.1.
State: Texas;
Area name: Killeen-Temple;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 349,131;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.38;
Percentage change in services per beneficiary served, 2000 to 2008:
1.4.
State: Texas;
Area name: Laredo;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 233,152;
Services per beneficiary served, 2000: 3.87;
Services per beneficiary served, 2008: 4.52;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
State: Texas;
Area name: Longview-Marshall;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 218,547;
Services per beneficiary served, 2000: 3.61;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
7.3.
State: Texas;
Area name: Lubbock;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 260,901;
Services per beneficiary served, 2000: 3.85;
Services per beneficiary served, 2008: 4.28;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
State: Texas;
Area name: McAllen-Edinburg-Mission;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 710,514;
Services per beneficiary served, 2000: 4.37;
Services per beneficiary served, 2008: 5.06;
Percentage change in services per beneficiary served, 2000 to 2008:
15.7.
State: Texas;
Area name: Odessa-Midland;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 255,978;
Services per beneficiary served, 2000: 3.68;
Services per beneficiary served, 2008: 3.37;
Percentage change in services per beneficiary served, 2000 to 2008:
-8.3.
State: Texas;
Area name: San Antonio;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,851,721;
Services per beneficiary served, 2000: 3.75;
Services per beneficiary served, 2008: 4.25;
Percentage change in services per beneficiary served, 2000 to 2008:
13.2.
State: Texas;
Area name: Waco;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 228,123;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
12.0.
State: Texas;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 1,164,156;
Services per beneficiary served, 2000: 3.55;
Services per beneficiary served, 2008: 3.91;
Percentage change in services per beneficiary served, 2000 to 2008:
10.3.
State: Texas;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 3,253,664;
Services per beneficiary served, 2000: 3.58;
Services per beneficiary served, 2008: 3.96;
Percentage change in services per beneficiary served, 2000 to 2008:
10.5.
State: Utah;
Area name: Provo-Orem;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 483,702;
Services per beneficiary served, 2000: 2.79;
Services per beneficiary served, 2008: 3.33;
Percentage change in services per beneficiary served, 2000 to 2008:
19.5.
State: Utah; Area name: Salt Lake City-Ogden;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,519,510;
Services per beneficiary served, 2000: 2.88;
Services per beneficiary served, 2008: 3.23;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
State: Utah;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 6,523;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
8.9.
State: Utah;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 635,595;
Services per beneficiary served, 2000: 2.83;
Services per beneficiary served, 2008: 3.26;
Percentage change in services per beneficiary served, 2000 to 2008:
15.3.
State: Vermont;
Area name: Burlington;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 207,361;
Services per beneficiary served, 2000: 2.98;
Services per beneficiary served, 2008: 3.14;
Percentage change in services per beneficiary served, 2000 to 2008:
5.4.
State: Vermont;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 413,893;
Services per beneficiary served, 2000: 2.88;
Services per beneficiary served, 2008: 3.13;
Percentage change in services per beneficiary served, 2000 to 2008:
8.6.
State: Virginia;
Area name: Arlington-Alexandria[C];
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,443,060;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 3.91;
Percentage change in services per beneficiary served, 2000 to 2008:
12.6.
State: Virginia;
Area name: Lynchburg;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 223,095;
Services per beneficiary served, 2000: 2.84;
Services per beneficiary served, 2008: 3.36;
Percentage change in services per beneficiary served, 2000 to 2008:
18.2.
State: Virginia;
Area name: Norfolk-Virginia Beach-Newport News;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,627,705;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
State: Virginia;
Area name: Richmond-Petersburg;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 1,096,629;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
7.4.
State: Virginia;
Area name: Roanoke;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 240,258;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.34;
Percentage change in services per beneficiary served, 2000 to 2008:
7.7.
State: Virginia;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 444,773;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.38;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
State: Virginia;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,613,240;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.36;
Percentage change in services per beneficiary served, 2000 to 2008:
11.0.
State: Washington;
Area name: Seattle-Bellevue-Everett;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 2,536,182;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
9.8.
State: Washington;
Area name: Tacoma;
Status[A]: Other area;
Type of area[B]: Metropolitan division;
Population, 2007: 773,165;
Services per beneficiary served, 2000: 3.04;
Services per beneficiary served, 2008: 3.42;
Percentage change in services per beneficiary served, 2000 to 2008:
12.5.
State: Washington;
Area name: Clark County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 418,070;
Services per beneficiary served, 2000: 2.93;
Services per beneficiary served, 2008: 3.50;
Percentage change in services per beneficiary served, 2000 to 2008:
19.5.
State: Washington;
Area name: Richland-Kennewick-Pasco;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 228,992;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.50;
Percentage change in services per beneficiary served, 2000 to 2008:
7.1.
State: Washington;
Area name: Spokane;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 456,175;
Services per beneficiary served, 2000: 3.00;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
17.4.
State: Washington;
Area name: Thurston County[C];
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 556,613;
Services per beneficiary served, 2000: 2.94;
Services per beneficiary served, 2008: 3.36;
Percentage change in services per beneficiary served, 2000 to 2008:
14.3.
State: Washington;
Area name: Yakima;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 233,062;
Services per beneficiary served, 2000: 2.88;
Services per beneficiary served, 2008: 3.28;
Percentage change in services per beneficiary served, 2000 to 2008:
13.8.
State: Washington;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 192,999;
Services per beneficiary served, 2000: 2.90;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
22.7.
State: Washington;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,073,166;
Services per beneficiary served, 2000: 2.99;
Services per beneficiary served, 2008: 3.29;
Percentage change in services per beneficiary served, 2000 to 2008:
9.9.
State: West Virginia;
Area name: Charleston;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 246,307;
Services per beneficiary served, 2000: 3.51;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
6.7.
State: West Virginia;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 530,438;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
11.7.
State: West Virginia;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,035,290;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 3.75;
Percentage change in services per beneficiary served, 2000 to 2008:
12.0.
State: Wisconsin;
Area name: Appleton-Oshkosh-Neenah;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 380,180;
Services per beneficiary served, 2000: 2.98;
Services per beneficiary served, 2008: 3.37;
Percentage change in services per beneficiary served, 2000 to 2008:
13.0.
State: Wisconsin;
Area name: Green Bay;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 243,132;
Services per beneficiary served, 2000: 2.95;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
16.3.
State: Wisconsin;
Area name: Madison;
Status[A]: Other area;
Type of area[B]: Large MSA;
Population, 2007: 476,785;
Services per beneficiary served, 2000: 2.92;
Services per beneficiary served, 2008: 3.32;
Percentage change in services per beneficiary served, 2000 to 2008:
13.8.
State: Wisconsin;
Area name: Milwaukee-Racine;
Status[A]: Potentially overserved area;
Type of area[B]: Large MSA;
Population, 2007: 1,739,497;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
15.9.
State: Wisconsin;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 1,000,654;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.65;
Percentage change in services per beneficiary served, 2000 to 2008:
16.9.
State: Wisconsin;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 1,761,392;
Services per beneficiary served, 2000: 2.96;
Services per beneficiary served, 2008: 3.38;
Percentage change in services per beneficiary served, 2000 to 2008:
14.0.
State: Wyoming;
Area name: Small metropolitan areas;
Status[A]: Other area;
Type of area[B]: Small MSA areas;
Population, 2007: 158,103;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
18.1.
State: Wyoming;
Area name: Rural counties;
Status[A]: Other area;
Type of area[B]: Rural areas;
Population, 2007: 364,727;
Services per beneficiary served, 2000: 2.99;
Services per beneficiary served, 2008: 3.21;
Percentage change in services per beneficiary served, 2000 to 2008:
7.4.
Source: GAO analysis of U.S. Census Bureau data and Medicare Part B
claims data for April 2000 and April 2008 from CMS.
[A] Potentially overserved areas are areas that were in the top half of
areas in both utilization of physician services in 2000 and growth in
utilization of physician services from 2000 to 2008. The rest of the
areas were designated as other areas.
[B] Counties were mapped to metropolitan divisions based on U.S. Census
Bureau designations. Counties mapped to MSAs based on U.S. Census
Bureau and OMB designations were classified as MSA areas. Small MSA
areas are MSAs with fewer than 200,000 in population grouped together
within each state. Rural areas include all rural counties within a
state.
[C] Some counties were reassigned to different areas as result of
overlap between metropolitan divisions and large MSAs or because the
original entity crossed state lines. The revised areas were renamed
after the remaining municipalities in the area or the largest county in
the area.
[End of table]
[End of section]
Appendix IV: Selected Physician Services in Potentially Overserved and
Other Areas:
Using the BETOS code to which each procedure code in our claims data
was assigned, we reviewed specific categories of physician services.
[Footnote 73] We collapsed data on other services and procedures into
summary categories. We classified geographic areas of the country by
type of area and utilization status. Our measure of utilization--
services per beneficiary served--is based on Medicare claims data for
services performed in the first 28 days of April 2000 and April 2008.
An area was designated as potentially overserved if it was in both the
top half of all areas in number of services per beneficiary served in
2000 and in the top half of the growth rate in services per beneficiary
served from 2000 to 2008. Table 13 shows the specific service
categories we reviewed, the change in the number of services provided
per 1,000 FFS beneficiaries from April 2000 to April 2008, and the
number of and difference in services provided in potentially overserved
and other areas.
Table 13: Selected Physician Services Provided per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved Areas and Other Areas:
Service category: All evaluation and management;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 15.1;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 1,229.2;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
948.1;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 29.7.
Service category: Office visits-new patients;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 6.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 34.8;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
28.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 22.1.
Service category: Office visits-established patients;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 14.1;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 566.6;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
474.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 19.4.
Service category: Hospital visits;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 28.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 297.9;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
211.8;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 40.7.
Service category: Emergency room visits;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 14.1;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 40.3;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
38.8;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 3.7.
Service category: All imaging;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 41.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 457.4;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
386.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 18.3.
Service category: CT scans;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 94.2;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 58.0;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
49.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 17.2.
Service category: MRIs;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 116.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 16.9;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
14.8;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 14.7.
Service category: Endoscopy;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 20.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 26.2;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
22.2;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 18.0.
Service category: Lab tests;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 548.2;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 45.1;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
34.6;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 30.6.
Service category: Other tests;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 26.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 166.1;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
121.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 36.7.
Service category: All major procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: -9.5;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 24.2;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
22.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 7.4.
Service category: Major cardiac procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: -22.9;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 12.1;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
10.6;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 14.5.
Service category: Major orthopedic procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 25.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 3.9;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
4.1;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: -4.8.
Service category: Minor procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 37.3;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 208.3;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
130.9;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 59.2.
Service category: Ambulatory procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 73.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 67.5;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
51.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 31.2.
Service category: Eye procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 28.5;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 13.4;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
12.0;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 12.0.
Service category: Anesthesia;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 16.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 22.6;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
16.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 36.6.
Service category: Oncology;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 10.2;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 34.3;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
26.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 29.9.
Service category: All services;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 25.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
areas, 2008: 2,314.7;
Services per 1,000 Medicare FFS beneficiaries in other areas, 2008:
1,788.9;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other areas, 2008: 29.4.
Source: GAO analysis of Medicare Part B claims data and enrollment data
from CMS.
Note: Potentially overserved areas are areas that were in the top half
of areas in both utilization of physician services in 2000 and growth
in utilization of physician services from 2000 to 2008. The rest of the
areas were designated as other areas.
[End of table]
[End of section]
Appendix V: Utilization Status of Medicare Physician Payment
Localities:
Medicare designates 87 distinct physician payment localities across the
50 states and the District of Columbia to adjust physician payments for
the geographic difference in the costs of operating a private medical
practice.[Footnote 74] We measured utilization in each of the Medicare
physician payment localities by examining the number of services per
beneficiary who received services in April 2000 and April 2008, and
ranked each payment locality by the level of utilization in 2000 and
the change in utilization from 2000 to 2008. To determine a locality's
utilization status, we designated Medicare physician payment localities
in the top half of both measures as potentially overserved payment
localities and designated the rest as other payment localities. Across
all Medicare physician payment localities, the median number of
services per beneficiary served was 3.34 in 2000 and 3.81 in 2008. The
median percentage change in services per beneficiary served from 2000
to 2008 was 13.4 percent. (See table 14.)
Table 14: Utilization Status of Medicare Physician Payment Localities:
Locality name: Alaska;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
4.0.
Locality name: Alabama;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.36;
Services per beneficiary served, 2008: 3.84;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
Locality name: Arkansas;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.36;
Services per beneficiary served, 2008: 3.73;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
Locality name: Arizona;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 4.03;
Percentage change in services per beneficiary served, 2000 to 2008:
16.2.
Locality name: Anaheim/Santa Ana, CA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.98;
Services per beneficiary served, 2008: 4.37;
Percentage change in services per beneficiary served, 2000 to 2008:
9.6.
Locality name: Los Angeles, CA;
Status: Other payment locality;
Services per beneficiary served, 2000: 4.48;
Services per beneficiary served, 2008: 4.63;
Percentage change in services per beneficiary served, 2000 to 2008:
3.4.
Locality name: Marin/Napa/Solano, CA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
18.3.
Locality name: Oakland/Berkley, CA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
16.5.
Locality name: Rest of California;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
Locality name: San Francisco, CA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
11.2.
Locality name: San Mateo, CA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
18.9.
Locality name: Santa Clara, CA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.01;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
Locality name: Ventura, CA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.75;
Services per beneficiary served, 2008: 4.08;
Percentage change in services per beneficiary served, 2000 to 2008:
8.8.
Locality name: Colorado;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
Locality name: Connecticut;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
20.8.
Locality name: DC and MD/VA suburbs;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.69;
Services per beneficiary served, 2008: 4.07;
Percentage change in services per beneficiary served, 2000 to 2008:
10.3.
Locality name: Delaware;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.87;
Percentage change in services per beneficiary served, 2000 to 2008:
17.6.
Locality name: Fort Lauderdale, FL;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 4.03;
Services per beneficiary served, 2008: 4.87;
Percentage change in services per beneficiary served, 2000 to 2008:
20.9.
Locality name: Miami, FL;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 4.49;
Services per beneficiary served, 2008: 5.10;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
Locality name: Rest of Florida;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.61;
Services per beneficiary served, 2008: 4.29;
Percentage change in services per beneficiary served, 2000 to 2008:
19.1.
Locality name: Atlanta, GA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.34;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
16.5.
Locality name: Rest of Georgia;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.22;
Services per beneficiary served, 2008: 3.65;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
Locality name: Hawaii/Guam;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.01;
Services per beneficiary served, 2008: 3.25;
Percentage change in services per beneficiary served, 2000 to 2008:
8.0.
Locality name: Iowa;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.14;
Services per beneficiary served, 2008: 3.45;
Percentage change in services per beneficiary served, 2000 to 2008:
9.6.
Locality name: Idaho;
Status: Other payment locality;
Services per beneficiary served, 2000: 2.90;
Services per beneficiary served, 2008: 3.15;
Percentage change in services per beneficiary served, 2000 to 2008:
8.9.
Locality name: Chicago, IL;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.79;
Services per beneficiary served, 2008: 4.55;
Percentage change in services per beneficiary served, 2000 to 2008:
20.0.
Locality name: East St. Louis, IL;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 3.80;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
Locality name: Rest of Illinois;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
Locality name: Suburban Chicago, IL;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 4.34;
Percentage change in services per beneficiary served, 2000 to 2008:
24.0.
Locality name: Indiana;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
17.7.
Locality name: Kansas;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.61;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
Locality name: Kentucky;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.34;
Services per beneficiary served, 2008: 3.84;
Percentage change in services per beneficiary served, 2000 to 2008:
15.0.
Locality name: New Orleans, LA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.79;
Services per beneficiary served, 2008: 4.18;
Percentage change in services per beneficiary served, 2000 to 2008:
10.4.
Locality name: Rest of Louisiana;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.57;
Services per beneficiary served, 2008: 3.98;
Percentage change in services per beneficiary served, 2000 to 2008:
11.4.
Locality name: Metropolitan Boston;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
9.8.
Locality name: Rest of Massachusetts;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
12.8.
Locality name: Baltimore/surrounding counties, MD;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.48;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
Locality name: Rest of Maryland;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
12.1.
Locality name: Rest of Maine;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.20;
Percentage change in services per beneficiary served, 2000 to 2008:
5.7.
Locality name: Southern Maine;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.37;
Percentage change in services per beneficiary served, 2000 to 2008:
8.1.
Locality name: Detroit, MI;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.84;
Services per beneficiary served, 2008: 4.73;
Percentage change in services per beneficiary served, 2000 to 2008:
23.1.
Locality name: Rest of Michigan;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
18.9.
Locality name: Minnesota;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.50;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
Locality name: Metropolitan Kansas City, MO;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.52;
Services per beneficiary served, 2008: 3.92;
Percentage change in services per beneficiary served, 2000 to 2008:
11.5.
Locality name: Metropolitan St. Louis, MO;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.97;
Percentage change in services per beneficiary served, 2000 to 2008:
17.6.
Locality name: Rest of Missouri;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.20;
Services per beneficiary served, 2008: 3.68;
Percentage change in services per beneficiary served, 2000 to 2008:
14.9.
Locality name: Mississippi;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
10.0.
Locality name: Montana;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.33;
Percentage change in services per beneficiary served, 2000 to 2008:
9.1.
Locality name: North Carolina;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
Locality name: North Dakota;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.04;
Services per beneficiary served, 2008: 3.34;
Percentage change in services per beneficiary served, 2000 to 2008:
9.9.
Locality name: Nebraska;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
16.0.
Locality name: New Hampshire;
Status: Other payment locality;
Services per beneficiary served, 2000: 2.99;
Services per beneficiary served, 2008: 3.42;
Percentage change in services per beneficiary served, 2000 to 2008:
14.4.
Locality name: Northern New Jersey;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.78;
Services per beneficiary served, 2008: 4.53;
Percentage change in services per beneficiary served, 2000 to 2008:
19.9.
Locality name: Rest of New Jersey;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.67;
Services per beneficiary served, 2008: 4.31;
Percentage change in services per beneficiary served, 2000 to 2008:
17.3.
Locality name: New Mexico;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.07;
Services per beneficiary served, 2008: 3.30;
Percentage change in services per beneficiary served, 2000 to 2008:
7.6.
Locality name: Nevada;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.75;
Services per beneficiary served, 2008: 4.25;
Percentage change in services per beneficiary served, 2000 to 2008:
13.2.
Locality name: Manhattan, NY;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.83;
Services per beneficiary served, 2008: 4.50;
Percentage change in services per beneficiary served, 2000 to 2008:
17.6.
Locality name: NYC suburbs/Long Island, NY;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.93;
Services per beneficiary served, 2008: 4.94;
Percentage change in services per beneficiary served, 2000 to 2008:
25.5.
Locality name: Poughkeepsie/Northern NYC suburbs, NY;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 4.09;
Percentage change in services per beneficiary served, 2000 to 2008:
21.5.
Locality name: Queens, NY;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.82;
Services per beneficiary served, 2008: 5.08;
Percentage change in services per beneficiary served, 2000 to 2008:
33.2.
Locality name: Rest of New York;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
12.9.
Locality name: Ohio;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.91;
Percentage change in services per beneficiary served, 2000 to 2008:
17.8.
Locality name: Oklahoma;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.53;
Percentage change in services per beneficiary served, 2000 to 2008:
7.9.
Locality name: Portland, Oregon;
Status: Other payment locality;
Services per beneficiary served, 2000: 2.96;
Services per beneficiary served, 2008: 3.37;
Percentage change in services per beneficiary served, 2000 to 2008:
13.7.
Locality name: Rest of Oregon;
Status: Other payment locality;
Services per beneficiary served, 2000: 2.89;
Services per beneficiary served, 2008: 3.22;
Percentage change in services per beneficiary served, 2000 to 2008:
11.5.
Locality name: Metropolitan Philadelphia, PA;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.77;
Services per beneficiary served, 2008: 4.34;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
Locality name: Rest of Pennsylvania;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.43;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
13.2.
Locality name: Rhode Island;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.73;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
Locality name: South Carolina;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
13.5.
Locality name: South Dakota;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.39;
Percentage change in services per beneficiary served, 2000 to 2008:
7.3.
Locality name: Tennessee;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.83;
Percentage change in services per beneficiary served, 2000 to 2008:
13.5.
Locality name: Austin, TX;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.53;
Services per beneficiary served, 2008: 3.94;
Percentage change in services per beneficiary served, 2000 to 2008:
11.6.
Locality name: Beaumont, TX;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.74;
Services per beneficiary served, 2008: 4.25;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
Locality name: Brazoria, TX;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.82;
Services per beneficiary served, 2008: 4.36;
Percentage change in services per beneficiary served, 2000 to 2008:
14.0.
Locality name: Dallas, TX;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.80;
Services per beneficiary served, 2008: 4.13;
Percentage change in services per beneficiary served, 2000 to 2008:
8.7.
Locality name: Fort Worth, TX;
Status: Potentially overserved payment locality;
Services per beneficiary served, 2000: 3.46;
Services per beneficiary served, 2008: 3.99;
Percentage change in services per beneficiary served, 2000 to 2008:
15.4.
Locality name: Galveston, TX;
Status: Other payment locality;
Services per beneficiary served, 2000: 4.12;
Services per beneficiary served, 2008: 4.57;
Percentage change in services per beneficiary served, 2000 to 2008:
10.8.
Locality name: Houston, TX;
Status: Other payment locality;
Services per beneficiary served, 2000: 5.12;
Services per beneficiary served, 2008: 4.91;
Percentage change in services per beneficiary served, 2000 to 2008:
-4.1.
Locality name: Rest of Texas;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.67;
Services per beneficiary served, 2008: 4.10;
Percentage change in services per beneficiary served, 2000 to 2008:
11.5.
Locality name: Utah;
Status: Other payment locality;
Services per beneficiary served, 2000: 2.86;
Services per beneficiary served, 2008: 3.25;
Percentage change in services per beneficiary served, 2000 to 2008:
13.8.
Locality name: Virginia;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.53;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
Locality name: Vermont;
Status: Other payment locality;
Services per beneficiary served, 2000: 2.91;
Services per beneficiary served, 2008: 3.13;
Percentage change in services per beneficiary served, 2000 to 2008:
7.7.
Locality name: Rest of Washington;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.00;
Services per beneficiary served, 2008: 3.40;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
Locality name: Seattle (King County), WA;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.41;
Percentage change in services per beneficiary served, 2000 to 2008:
8.8.
Locality name: Wisconsin;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
15.5.
Locality name: West Virginia;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.75;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
Locality name: Wyoming;
Status: Other payment locality;
Services per beneficiary served, 2000: 3.00;
Services per beneficiary served, 2008: 3.34;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
Source: GAO analysis of Medicare Part B claims data, enrollment data,
and physician payment locality data from CMS.
Notes: Potentially overserved Medicare physician payment localities are
localities that were in the top half of localities in both utilization
of physician services in 2000 and growth in utilization of physician
services from 2000 to 2008. The rest of the Medicare physician
localities were designated as other payment localities. We combined
certain Medicare physician payment localities in California, Kansas,
and Missouri. We excluded data from the Puerto Rico and U.S. Virgin
Islands Medicare physician payment localities.
[End of table]
[End of section]
Appendix VI: Selected Physician Services in Potentially Overserved and
Other Medicare Physician Payment Localities:
Using the BETOS code to which each procedure code in our claims data
was assigned, we reviewed specific categories of physician
services.[Footnote 75] We collapsed data on other services and
procedures into summary categories. We classified Medicare physician
payment localities by utilization status. Our measure of utilization--
services per beneficiary served--is based on Medicare claims data for
services performed in the first 28 days of April 2000 and April 2008.
[Footnote 76] A Medicare physician payment locality was designated as
potentially overserved if it was in both the top half of all areas in
number of services per beneficiary served in 2000 and in the top half
of the growth rate in services per beneficiary served from 2000 to
2008. Table 15 shows the specific service categories we reviewed, the
change in the number of services provided per 1,000 FFS beneficiaries
from April 2000 to April 2008, and the number of and difference in
services provided in potentially overserved and other Medicare
physician payment localities.
Table 15: Selected Physician Services Provided per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved and Other Medicare Physician
Payment Localities:
Service category: All evaluation and management;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 15.1;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 1,243.4;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 961.2;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 29.4.
Service category: Office visits-new patients;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 6.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 35.6;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 28.6;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 24.5.
Service category: Office visits-established patients;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 14.1;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 579.1;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 475.6;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 21.8.
Service category: Hospital visits;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 28.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 295.6;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 218.3;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 35.4.
Service category: Emergency room visits;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 14.1;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 40.0;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 39.0;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 2.6.
Service category: All imaging;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 41.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 458.0;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 391.0;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 17.1.
Service category: CT scans;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 94.2;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 58.0;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 50.1;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 15.8.
Service category: MRIs;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 116.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 17.3;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 14.7;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 17.6.
Service category: Endoscopy;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 20.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 26.4;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 22.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 17.9.
Service category: Lab tests;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 548.2;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 43.6;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 35.8;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 21.8.
Service category: Other tests;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 26.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 168.6;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 123.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 36.6.
Service category: All major procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: -9.5;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 24.0;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 22.7;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 5.7.
Service category: Major cardiac procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: -22.9;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 12.0;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 10.7;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 12.5.
Service category: Major orthopedic procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 25.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 3.9;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 4.1;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: -5.3.
Service category: Minor procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 37.3;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 212.8;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 134.3;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 58.4.
Service category: Ambulatory procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 73.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 69.3;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 51.9;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 33.6.
Service category: Eye procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 28.5;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 13.6;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 12.0;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 12.9.
Service category: Anesthesia;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 16.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 22.2;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 17.1;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 29.9.
Service category: Oncology;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 10.2;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 34.1;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 27.0;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 26.5.
Service category: All services;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 25.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
payment localities, 2008: 2,337.0;
Services per 1,000 Medicare FFS beneficiaries in other payment
localities, 2008: 1,815.0;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other payment localities, 2008: 28.8.
Source: GAO analysis of Medicare Part B claims data, enrollment data,
and physician payment locality data from CMS.
Notes: Potentially overserved Medicare physician payment localities are
localities that were in the top half of localities in both utilization
of physician services in 2000 and growth in utilization of physician
services from 2000 to 2008. The rest of the localities were designated
as other Medicare physician payment localities. We combined certain
Medicare physician payment localities in California, Kansas, and
Missouri. We excluded data from the Puerto Rico and U.S. Virgin Islands
Medicare physician payment localities.
[End of table]
[End of section]
Appendix VII: Utilization Status of Hospital Referral Regions:
Hospital referral regions (HRR) are the 306 distinct geographic regions
designated by Dartmouth researchers to represent regional health care
markets for tertiary medical care. Each HRR contains at least one
hospital that performs major cardiovascular procedures and
neurosurgery. We measured utilization in each of the HRRs by examining
the number of services per beneficiary who received services in April
2000 and April 2008, and ranked each HRR by level of utilization in
2000 and change in utilization from 2000 to 2008. To determine an HRR's
utilization status, we designated HRRs in the top half of both measures
as potentially overserved HRRs and designated the rest as other HRRs.
Across all HRRs, the median number of services per beneficiary served
was 3.26 in 2000 and 3.72 in 2008. The median percentage change in
services per beneficiary served from 2000 to 2008 was 13.7 percent.
(See table 16.)
Table 16: Utilization Status of Hospital Referral Regions:
HRR name: Birmingham, AL[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.85;
Percentage change in services per beneficiary served, 2000 to 2008:
14.3.
HRR name: Dothan, AL[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
12.6.
HRR name: Huntsville, AL[A]; Status:
Other HRR;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
17.4.
HRR name: Mobile, AL[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.58;
Services per beneficiary served, 2008: 4.00;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
HRR name: Montgomery, AL;
Status: Other HRR;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
13.1.
HRR name: Tuscaloosa, AL;
Status: Other HRR;
Services per beneficiary served, 2000: 3.55;
Services per beneficiary served, 2008: 4.03;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
HRR name: Anchorage, AK;
Status: Other HRR;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
3.9.
HRR name: Mesa, AZ;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.48;
Services per beneficiary served, 2008: 4.06;
Percentage change in services per beneficiary served, 2000 to 2008:
16.8.
HRR name: Phoenix, AZ[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 4.06;
Percentage change in services per beneficiary served, 2000 to 2008:
16.1.
HRR name: Sun City, AZ;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.65;
Services per beneficiary served, 2008: 4.29;
Percentage change in services per beneficiary served, 2000 to 2008:
17.5.
HRR name: Tucson, AZ;
Status: Other HRR;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.86;
Percentage change in services per beneficiary served, 2000 to 2008:
18.6.
HRR name: Fort Smith, AR[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.36;
Services per beneficiary served, 2008: 3.60;
Percentage change in services per beneficiary served, 2000 to 2008:
7.2.
HRR name: Jonesboro, AR[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
HRR name: Little Rock, AR;
Status: Other HRR;
Services per beneficiary served, 2000: 3.38;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
11.7.
HRR name: Springdale, AR[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.53;
Percentage change in services per beneficiary served, 2000 to 2008:
10.0.
HRR name: Texarkana, AR[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
7.8.
HRR name: Orange County, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.98;
Services per beneficiary served, 2008: 4.36;
Percentage change in services per beneficiary served, 2000 to 2008:
9.5.
HRR name: Bakersfield, CA;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.35;
Services per beneficiary served, 2008: 3.95;
Percentage change in services per beneficiary served, 2000 to 2008:
17.7.
HRR name: Chico, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.44;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
HRR name: Contra Costa County, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.99;
Percentage change in services per beneficiary served, 2000 to 2008:
24.2.
HRR name: Fresno, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.11;
Services per beneficiary served, 2008: 3.65;
Percentage change in services per beneficiary served, 2000 to 2008:
17.4.
HRR name: Los Angeles, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 4.48;
Services per beneficiary served, 2008: 4.64;
Percentage change in services per beneficiary served, 2000 to 2008:
3.5.
HRR name: Modesto, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
13.7.
HRR name: Napa, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.54;
Percentage change in services per beneficiary served, 2000 to 2008:
9.3.
HRR name: Alameda County, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
11.2.
HRR name: Palm Springs/Rancho Mira, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.77;
Services per beneficiary served, 2008: 4.07;
Percentage change in services per beneficiary served, 2000 to 2008:
7.8.
HRR name: Redding, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
3.3.
HRR name: Sacramento, CA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.17;
Services per beneficiary served, 2008: 3.48;
Percentage change in services per beneficiary served, 2000 to 2008:
9.8.
HRR name: Salinas, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.54;
Percentage change in services per beneficiary served, 2000 to 2008:
7.5.
HRR name: San Bernardino, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.73;
Services per beneficiary served, 2008: 4.07;
Percentage change in services per beneficiary served, 2000 to 2008:
9.2.
HRR name: San Diego, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.59;
Services per beneficiary served, 2008: 3.97;
Percentage change in services per beneficiary served, 2000 to 2008:
10.7.
HRR name: San Francisco, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
13.8.
HRR name: San Jose, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.02;
Services per beneficiary served, 2008: 3.53;
Percentage change in services per beneficiary served, 2000 to 2008:
17.1.
HRR name: San Luis Obispo, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.47;
Percentage change in services per beneficiary served, 2000 to 2008:
12.7.
HRR name: San Mateo County, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
18.3.
HRR name: Santa Barbara, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.42;
Services per beneficiary served, 2008: 3.64;
Percentage change in services per beneficiary served, 2000 to 2008:
6.4.
HRR name: Santa Cruz, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
HRR name: Santa Rosa, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
HRR name: Stockton, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.48;
Percentage change in services per beneficiary served, 2000 to 2008:
9.4.
HRR name: Ventura, CA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.76;
Services per beneficiary served, 2008: 4.08;
Percentage change in services per beneficiary served, 2000 to 2008:
8.4.
HRR name: Boulder, CO;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 4.07;
Percentage change in services per beneficiary served, 2000 to 2008:
16.3.
HRR name: Colorado Springs, CO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.02;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
17.8.
HRR name: Denver, CO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
14.9.
HRR name: Fort Collins, CO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.98;
Services per beneficiary served, 2008: 3.44;
Percentage change in services per beneficiary served, 2000 to 2008:
15.5.
HRR name: Grand Junction, CO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.71;
Services per beneficiary served, 2008: 3.11;
Percentage change in services per beneficiary served, 2000 to 2008:
15.1.
HRR name: Greeley, CO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.00;
Services per beneficiary served, 2008: 3.34;
Percentage change in services per beneficiary served, 2000 to 2008:
11.4.
HRR name: Pueblo, CO;
Status: Other HRR;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.40;
Percentage change in services per beneficiary served, 2000 to 2008:
10.2.
HRR name: Bridgeport, CT;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.41;
Services per beneficiary served, 2008: 4.18;
Percentage change in services per beneficiary served, 2000 to 2008:
22.5.
HRR name: Hartford, CT[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.00;
Services per beneficiary served, 2008: 3.62;
Percentage change in services per beneficiary served, 2000 to 2008:
20.7.
HRR name: New Haven, CT[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.89;
Percentage change in services per beneficiary served, 2000 to 2008:
20.2.
HRR name: Wilmington, DE[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.34;
Services per beneficiary served, 2008: 3.97;
Percentage change in services per beneficiary served, 2000 to 2008:
19.0.
HRR name: Washington, DC[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.62;
Services per beneficiary served, 2008: 3.95;
Percentage change in services per beneficiary served, 2000 to 2008:
9.2.
HRR name: Bradenton, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.61;
Services per beneficiary served, 2008: 4.54;
Percentage change in services per beneficiary served, 2000 to 2008:
25.7.
HRR name: Clearwater, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.70;
Services per beneficiary served, 2008: 4.42;
Percentage change in services per beneficiary served, 2000 to 2008:
19.5.
HRR name: Fort Lauderdale, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 4.18;
Services per beneficiary served, 2008: 5.05;
Percentage change in services per beneficiary served, 2000 to 2008:
20.7.
HRR name: Fort Myers, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.74;
Services per beneficiary served, 2008: 4.57;
Percentage change in services per beneficiary served, 2000 to 2008:
22.1.
HRR name: Gainesville, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.52;
Services per beneficiary served, 2008: 4.02;
Percentage change in services per beneficiary served, 2000 to 2008:
14.4.
HRR name: Hudson, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.87;
Services per beneficiary served, 2008: 4.60;
Percentage change in services per beneficiary served, 2000 to 2008:
18.9.
HRR name: Jacksonville, FL[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.73;
Services per beneficiary served, 2008: 4.46;
Percentage change in services per beneficiary served, 2000 to 2008:
19.4.
HRR name: Lakeland, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.46;
Services per beneficiary served, 2008: 4.12;
Percentage change in services per beneficiary served, 2000 to 2008:
19.1.
HRR name: Miami, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 4.43;
Services per beneficiary served, 2008: 5.09;
Percentage change in services per beneficiary served, 2000 to 2008:
14.8.
HRR name: Ocala, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.49;
Services per beneficiary served, 2008: 4.01;
Percentage change in services per beneficiary served, 2000 to 2008:
14.9.
HRR name: Orlando, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.65;
Services per beneficiary served, 2008: 4.38;
Percentage change in services per beneficiary served, 2000 to 2008:
20.1.
HRR name: Ormond Beach, FL;
Status: Other HRR;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 4.06;
Percentage change in services per beneficiary served, 2000 to 2008:
25.5.
HRR name: Panama City, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.53;
Services per beneficiary served, 2008: 4.16;
Percentage change in services per beneficiary served, 2000 to 2008:
17.9.
HRR name: Pensacola, FL[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.83;
Percentage change in services per beneficiary served, 2000 to 2008:
15.6.
HRR name: Sarasota, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.61;
Services per beneficiary served, 2008: 4.26;
Percentage change in services per beneficiary served, 2000 to 2008:
18.1.
HRR name: St. Petersburg, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.71;
Services per beneficiary served, 2008: 4.55;
Percentage change in services per beneficiary served, 2000 to 2008:
22.8.
HRR name: Tallahassee, FL[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.19;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
HRR name: Tampa, FL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.72;
Services per beneficiary served, 2008: 4.38;
Percentage change in services per beneficiary served, 2000 to 2008:
17.7.
HRR name: Albany, GA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.41;
Percentage change in services per beneficiary served, 2000 to 2008:
5.2.
HRR name: Atlanta, GA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
16.5.
HRR name: Augusta, GA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.48;
Percentage change in services per beneficiary served, 2000 to 2008:
8.6.
HRR name: Columbus, GA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.53;
Percentage change in services per beneficiary served, 2000 to 2008:
15.9.
HRR name: Macon, GA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.20;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
18.1.
HRR name: Rome, GA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
17.9.
HRR name: Savannah, GA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.42;
Services per beneficiary served, 2008: 3.79;
Percentage change in services per beneficiary served, 2000 to 2008:
10.7.
HRR name: Honolulu, HI;
Status: Other HRR;
Services per beneficiary served, 2000: 3.01;
Services per beneficiary served, 2008: 3.25;
Percentage change in services per beneficiary served, 2000 to 2008:
8.0.
HRR name: Boise, ID[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.90;
Services per beneficiary served, 2008: 3.15;
Percentage change in services per beneficiary served, 2000 to 2008:
8.7.
HRR name: Idaho Falls, ID;
Status: Other HRR;
Services per beneficiary served, 2000: 2.94;
Services per beneficiary served, 2008: 3.19;
Percentage change in services per beneficiary served, 2000 to 2008:
8.5.
HRR name: Aurora, IL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.96;
Percentage change in services per beneficiary served, 2000 to 2008:
20.4.
HRR name: Blue Island, IL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.70;
Services per beneficiary served, 2008: 4.56;
Percentage change in services per beneficiary served, 2000 to 2008:
23.0.
HRR name: Chicago, IL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 4.05;
Services per beneficiary served, 2008: 4.75;
Percentage change in services per beneficiary served, 2000 to 2008:
17.2.
HRR name: Elgin, IL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 4.42;
Percentage change in services per beneficiary served, 2000 to 2008:
27.6.
HRR name: Evanston, IL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.48;
Services per beneficiary served, 2008: 4.27;
Percentage change in services per beneficiary served, 2000 to 2008:
22.7.
HRR name: Hinsdale, IL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.51;
Services per beneficiary served, 2008: 4.22;
Percentage change in services per beneficiary served, 2000 to 2008:
20.3.
HRR name: Joliet, IL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.73;
Services per beneficiary served, 2008: 4.48;
Percentage change in services per beneficiary served, 2000 to 2008:
20.1.
HRR name: Melrose Park, IL;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.52;
Services per beneficiary served, 2008: 4.26;
Percentage change in services per beneficiary served, 2000 to 2008:
20.9.
HRR name: Peoria, IL;
Status: Other HRR;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.68;
Percentage change in services per beneficiary served, 2000 to 2008:
16.6.
HRR name: Rockford, IL;
Status: Other HRR;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
21.9.
HRR name: Springfield, IL[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.41;
Services per beneficiary served, 2008: 3.86;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
HRR name: Urbana, IL[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
HRR name: Bloomington, IL;
Status: Other HRR;
Services per beneficiary served, 2000: 3.19;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
16.4.
HRR name: Evansville, IN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.14;
Services per beneficiary served, 2008: 3.63;
Percentage change in services per beneficiary served, 2000 to 2008:
15.5.
HRR name: Fort Wayne, IN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.96;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
20.4.
HRR name: Gary, IN[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.51;
Services per beneficiary served, 2008: 4.24;
Percentage change in services per beneficiary served, 2000 to 2008:
20.8.
HRR name: Indianapolis, IN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
HRR name: Lafayette, IN;
Status: Other HRR;
Services per beneficiary served, 2000: 2.98;
Services per beneficiary served, 2008: 3.65;
Percentage change in services per beneficiary served, 2000 to 2008:
22.4.
HRR name: Muncie, IN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.61;
Percentage change in services per beneficiary served, 2000 to 2008:
13.8.
HRR name: Munster, IN[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.61;
Services per beneficiary served, 2008: 4.65;
Percentage change in services per beneficiary served, 2000 to 2008:
28.7.
HRR name: South Bend, IN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.99;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
17.8.
HRR name: Terre Haute, IN[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.87;
Percentage change in services per beneficiary served, 2000 to 2008:
16.4.
HRR name: Cedar Rapids, IA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.38;
Percentage change in services per beneficiary served, 2000 to 2008:
9.5.
HRR name: Davenport, IA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.22;
Services per beneficiary served, 2008: 3.73;
Percentage change in services per beneficiary served, 2000 to 2008:
15.8.
HRR name: Des Moines, IA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.22;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
9.3.
HRR name: Dubuque, IA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.97;
Services per beneficiary served, 2008: 3.22;
Percentage change in services per beneficiary served, 2000 to 2008:
8.4.
HRR name: Iowa City, IA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.95;
Services per beneficiary served, 2008: 3.26;
Percentage change in services per beneficiary served, 2000 to 2008:
10.3.
HRR name: Mason City, IA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.24;
Percentage change in services per beneficiary served, 2000 to 2008:
7.1.
HRR name: Sioux City, IA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.36;
Percentage change in services per beneficiary served, 2000 to 2008:
5.6.
HRR name: Waterloo, IA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.22;
Services per beneficiary served, 2008: 3.64;
Percentage change in services per beneficiary served, 2000 to 2008:
13.2.
HRR name: Topeka, KS;
Status: Other HRR;
Services per beneficiary served, 2000: 2.93;
Services per beneficiary served, 2008: 3.44;
Percentage change in services per beneficiary served, 2000 to 2008:
17.5.
HRR name: Wichita, KS[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
10.9.
HRR name: Covington, KY[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 4.13;
Percentage change in services per beneficiary served, 2000 to 2008:
27.1.
HRR name: Lexington, KY[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.19;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
18.5.
HRR name: Louisville, KY[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.48;
Services per beneficiary served, 2008: 3.94;
Percentage change in services per beneficiary served, 2000 to 2008:
13.0.
HRR name: Owensboro, KY[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.46;
Services per beneficiary served, 2008: 3.64;
Percentage change in services per beneficiary served, 2000 to 2008:
5.3.
HRR name: Paducah, KY[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.68;
Percentage change in services per beneficiary served, 2000 to 2008:
14.9.
HRR name: Alexandria, LA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.37;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
HRR name: Baton Rouge, LA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.68;
Services per beneficiary served, 2008: 4.08;
Percentage change in services per beneficiary served, 2000 to 2008:
10.8.
HRR name: Houma, LA;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.92;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
HRR name: Lafayette, LA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
10.9.
HRR name: Lake Charles, LA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.56;
Services per beneficiary served, 2008: 3.62;
Percentage change in services per beneficiary served, 2000 to 2008:
1.6.
HRR name: Metairie, LA;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.68;
Services per beneficiary served, 2008: 4.29;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
HRR name: Monroe, LA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.85;
Services per beneficiary served, 2008: 4.19;
Percentage change in services per beneficiary served, 2000 to 2008:
8.9.
HRR name: New Orleans, LA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.83;
Services per beneficiary served, 2008: 4.16;
Percentage change in services per beneficiary served, 2000 to 2008:
8.8.
HRR name: Shreveport, LA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.54;
Services per beneficiary served, 2008: 3.98;
Percentage change in services per beneficiary served, 2000 to 2008:
12.4.
HRR name: Slidell, LA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.72;
Services per beneficiary served, 2008: 4.04;
Percentage change in services per beneficiary served, 2000 to 2008:
8.7.
HRR name: Bangor, ME;
Status: Other HRR;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.23;
Percentage change in services per beneficiary served, 2000 to 2008:
4.2.
HRR name: Portland, ME[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.30;
Percentage change in services per beneficiary served, 2000 to 2008:
8.9.
HRR name: Baltimore, MD;
Status: Other HRR;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 3.90;
Percentage change in services per beneficiary served, 2000 to 2008:
12.3.
HRR name: Salisbury, MD[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.36;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
HRR name: Takoma Park, MD;
Status: Other HRR;
Services per beneficiary served, 2000: 3.72;
Services per beneficiary served, 2008: 4.15;
Percentage change in services per beneficiary served, 2000 to 2008:
11.5.
HRR name: Boston, MA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.42;
Services per beneficiary served, 2008: 3.79;
Percentage change in services per beneficiary served, 2000 to 2008:
10.9.
HRR name: Springfield, MA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.47;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
HRR name: Worcester, MA;
Status: Other HRR; Services per beneficiary served, 2000: 3.22;
Services per beneficiary served, 2008: 3.62;
Percentage change in services per beneficiary served, 2000 to 2008:
12.5.
HRR name: Ann Arbor, MI;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 4.11;
Percentage change in services per beneficiary served, 2000 to 2008:
17.3.
HRR name: Dearborn, MI;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.78;
Services per beneficiary served, 2008: 4.73;
Percentage change in services per beneficiary served, 2000 to 2008:
25.1.
HRR name: Detroit, MI;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.94;
Services per beneficiary served, 2008: 4.85;
Percentage change in services per beneficiary served, 2000 to 2008:
23.2.
HRR name: Flint, MI;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.64;
Services per beneficiary served, 2008: 4.43;
Percentage change in services per beneficiary served, 2000 to 2008:
21.7.
HRR name: Grand Rapids, MI;
Status: Other HRR;
Services per beneficiary served, 2000: 2.97;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
20.9.
HRR name: Kalamazoo, MI;
Status: Other HRR;
Services per beneficiary served, 2000: 3.01;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
16.8.
HRR name: Lansing, MI;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
18.4.
HRR name: Marquette, MI[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.35;
Percentage change in services per beneficiary served, 2000 to 2008:
10.5.
HRR name: Muskegon, MI;
Status: Other HRR;
Services per beneficiary served, 2000: 2.98;
Services per beneficiary served, 2008: 3.38;
Percentage change in services per beneficiary served, 2000 to 2008:
13.2.
HRR name: Petoskey, MI;
Status: Other HRR;
Services per beneficiary served, 2000: 3.07;
Services per beneficiary served, 2008: 3.89;
Percentage change in services per beneficiary served, 2000 to 2008:
26.9.
HRR name: Pontiac, MI;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.76;
Services per beneficiary served, 2008: 4.69;
Percentage change in services per beneficiary served, 2000 to 2008:
24.6.
HRR name: Royal Oak, MI;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.86;
Services per beneficiary served, 2008: 4.83;
Percentage change in services per beneficiary served, 2000 to 2008:
25.4.
HRR name: Saginaw, MI;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.98;
Percentage change in services per beneficiary served, 2000 to
2008: 17.0.
HRR name: St. Joseph, MI;
Status: Other HRR;
Services per beneficiary served, 2000: 2.98;
Services per beneficiary served, 2008: 3.63;
Percentage change in services per beneficiary served, 2000 to 2008:
21.8.
HRR name: Traverse City, MI;
Status: Other HRR;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
12.1.
HRR name: Duluth, MN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.96;
Services per beneficiary served, 2008: 3.34;
Percentage change in services per beneficiary served, 2000 to 2008:
12.8.
HRR name: Minneapolis, MN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.02;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
HRR name: Rochester, MN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.34;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
6.5.
HRR name: St. Cloud, MN;
Status: Other HRR;
Services per beneficiary served, 2000: 3.04;
Services per beneficiary served, 2008: 3.48;
Percentage change in services per beneficiary served, 2000 to 2008:
14.5.
HRR name: St. Paul, MN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.53;
Percentage change in services per beneficiary served, 2000 to 2008:
14.5.
HRR name: Gulfport, MS;
Status: Other HRR;
Services per beneficiary served, 2000: 3.80;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
2.0.
HRR name: Hattiesburg, MS;
Status: Other HRR;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 3.79;
Percentage change in services per beneficiary served, 2000 to 2008:
8.3.
HRR name: Jackson, MS[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.65;
Percentage change in services per beneficiary served, 2000 to 2008:
11.6.
HRR name: Meridian, MS[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.46;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
8.0.
HRR name: Oxford, MS;
Status: Other HRR;
Services per beneficiary served, 2000: 3.34;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
7.4.
HRR name: Tupelo, MS[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.06;
Services per beneficiary served, 2008: 3.45;
Percentage change in services per beneficiary served, 2000 to 2008:
12.7.
HRR name: Cape Girardeau, MO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.21;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
16.4.
HRR name: Columbia, MO[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
14.9.
HRR name: Joplin, MO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.17;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
13.0.
HRR name: Kansas City, MO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 3.86;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
HRR name: Springfield, MO[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.02;
Services per beneficiary served, 2008: 3.46;
Percentage change in services per beneficiary served, 2000 to 2008:
14.4.
HRR name: St. Louis, MO[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.36;
Services per beneficiary served, 2008: 3.89;
Percentage change in services per beneficiary served, 2000 to 2008:
15.9.
HRR name: Billings, MT[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.01;
Services per beneficiary served, 2008: 3.21;
Percentage change in services per beneficiary served, 2000 to 2008:
6.5.
HRR name: Great Falls, MT;
Status: Other HRR;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
HRR name: Missoula, MT[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.04;
Services per beneficiary served, 2008: 3.30;
Percentage change in services per beneficiary served, 2000 to 2008:
8.5.
HRR name: Lincoln, NE[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.06;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
16.0.
HRR name: Omaha, NE[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.75;
Percentage change in services per beneficiary served, 2000 to 2008:
15.6.
HRR name: Las Vegas, NV[A];
Status: Other HRR;
Services per beneficiary served, 2000: 4.06;
Services per beneficiary served, 2008: 4.56;
Percentage change in services per beneficiary served, 2000 to 2008:
12.2.
HRR name: Reno, NV[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.14;
Services per beneficiary served, 2008: 3.50;
Percentage change in services per beneficiary served, 2000 to 2008:
11.3.
HRR name: Lebanon, NH[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.84;
Services per beneficiary served, 2008: 3.12;
Percentage change in services per beneficiary served, 2000 to 2008:
9.9.
HRR name: Manchester, NH;
Status: Other HRR;
Services per beneficiary served, 2000: 3.01;
Services per beneficiary served, 2008: 3.45;
Percentage change in services per beneficiary served, 2000 to 2008:
14.6.
HRR name: Camden, NJ;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.66;
Services per beneficiary served, 2008: 4.31;
Percentage change in services per beneficiary served, 2000 to 2008:
17.6.
HRR name: Hackensack, NJ[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.80;
Services per beneficiary served, 2008: 4.60;
Percentage change in services per beneficiary served, 2000 to 2008:
21.0.
HRR name: Morristown, NJ[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.54;
Services per beneficiary served, 2008: 4.24;
Percentage change in services per beneficiary served, 2000 to 2008:
19.6.
HRR name: New Brunswick, NJ;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.85;
Services per beneficiary served, 2008: 4.54;
Percentage change in services per beneficiary served, 2000 to 2008:
17.7.
HRR name: Newark, NJ;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.92;
Services per beneficiary served, 2008: 4.77;
Percentage change in services per beneficiary served, 2000 to 2008:
21.7.
HRR name: Paterson, NJ;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.65;
Services per beneficiary served, 2008: 4.40;
Percentage change in services per beneficiary served, 2000 to 2008:
20.5.
HRR name: Ridgewood, NJ[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.77;
Services per beneficiary served, 2008: 4.51;
Percentage change in services per beneficiary served, 2000 to 2008:
19.6.
HRR name: Albuquerque, NM[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.01;
Services per beneficiary served, 2008: 3.18;
Percentage change in services per beneficiary served, 2000 to 2008:
5.9.
HRR name: Albany, NY[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
17.9.
HRR name: Binghamton, NY[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.09;
Services per beneficiary served, 2008: 3.40;
Percentage change in services per beneficiary served, 2000 to 2008:
9.8.
HRR name: Bronx, NY;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.90;
Services per beneficiary served, 2008: 4.70;
Percentage change in services per beneficiary served, 2000 to 2008:
20.6.
HRR name: Buffalo, NY[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.13;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
HRR name: Elmira, NY[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.17;
Services per beneficiary served, 2008: 3.63;
Percentage change in services per beneficiary served, 2000 to 2008:
14.3.
HRR name: East Long Island, NY;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.84;
Services per beneficiary served, 2008: 4.86;
Percentage change in services per beneficiary served, 2000 to 2008:
26.3.
HRR name: Manhattan, NY;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 4.00;
Services per beneficiary served, 2008: 5.13;
Percentage change in services per beneficiary served, 2000 to 2008:
28.5.
HRR name: Rochester, NY;
Status: Other HRR;
Services per beneficiary served, 2000: 2.88;
Services per beneficiary served, 2008: 3.29;
Percentage change in services per beneficiary served, 2000 to 2008:
14.3.
HRR name: Syracuse, NY;
Status: Other HRR;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
10.5.
HRR name: White Plains, NY;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.77;
Services per beneficiary served, 2008: 4.44;
Percentage change in services per beneficiary served, 2000 to 2008:
17.8.
HRR name: Asheville, NC;
Status: Other HRR;
Services per beneficiary served, 2000: 3.06;
Services per beneficiary served, 2008: 3.29;
Percentage change in services per beneficiary served, 2000 to 2008:
7.5.
HRR name: Charlotte, NC[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.65;
Percentage change in services per beneficiary served, 2000 to 2008:
15.3.
HRR name: Durham, NC[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.06;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
16.4.
HRR name: Greensboro, NC;
Status: Other HRR;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.47;
Percentage change in services per beneficiary served, 2000 to 2008:
11.5.
HRR name: Greenville, NC;
Status: Other HRR;
Services per beneficiary served, 2000: 3.23;
Services per beneficiary served, 2008: 3.59;
Percentage change in services per beneficiary served, 2000 to 2008:
11.3.
HRR name: Hickory, NC;
Status: Other HRR;
Services per beneficiary served, 2000: 3.07;
Services per beneficiary served, 2008: 3.45;
Percentage change in services per beneficiary served, 2000 to 2008:
12.1.
HRR name: Raleigh, NC;
Status: Other HRR;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.64;
Percentage change in services per beneficiary served, 2000 to 2008:
16.6.
HRR name: Wilmington, NC;
Status: Other HRR;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
7.6.
HRR name: Winston-Salem, NC[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.60;
Percentage change in services per beneficiary served, 2000 to 2008:
16.1.
HRR name: Bismarck, ND[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.36;
Percentage change in services per beneficiary served, 2000 to 2008:
5.8.
HRR name: Fargo, ND[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.91;
Services per beneficiary served, 2008: 3.26;
Percentage change in services per beneficiary served, 2000 to 2008:
12.0.
HRR name: Grand Forks, ND[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.00;
Services per beneficiary served, 2008: 3.49;
Percentage change in services per beneficiary served, 2000 to 2008:
16.1.
HRR name: Minot, ND[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.94;
Services per beneficiary served, 2008: 3.28;
Percentage change in services per beneficiary served, 2000 to 2008:
11.7.
HRR name: Akron, OH;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.39;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
14.6.
HRR name: Canton, OH;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.29;
Services per beneficiary served, 2008: 3.77;
Percentage change in services per beneficiary served, 2000 to 2008:
14.8.
HRR name: Cincinnati, OH[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.16;
Services per beneficiary served, 2008: 3.79;
Percentage change in services per beneficiary served, 2000 to 2008:
20.0.
HRR name: Cleveland, OH;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.41;
Services per beneficiary served, 2008: 4.11;
Percentage change in services per beneficiary served, 2000 to 2008:
20.6.
HRR name: Columbus, OH[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
14.5.
HRR name: Dayton, OH;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.95;
Percentage change in services per beneficiary served, 2000 to 2008:
21.1.
HRR name: Elyria, OH;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.43;
Services per beneficiary served, 2008: 4.16;
Percentage change in services per beneficiary served, 2000 to 2008:
21.1.
HRR name: Kettering, OH;
Status: Other HRR;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.85;
Percentage change in services per beneficiary served, 2000 to 2008:
25.2.
HRR name: Toledo, OH[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.46;
Services per beneficiary served, 2008: 3.97;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
HRR name: Youngstown, OH[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.53;
Services per beneficiary served, 2008: 4.19;
Percentage change in services per beneficiary served, 2000 to 2008:
18.7.
HRR name: Lawton, OK;
Status: Other HRR;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.57;
Percentage change in services per beneficiary served, 2000 to 2008:
12.1.
HRR name: Oklahoma City, OK[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.56;
Percentage change in services per beneficiary served, 2000 to 2008:
9.2.
HRR name: Tulsa, OK[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.44;
Percentage change in services per beneficiary served, 2000 to 2008:
5.8.
HRR name: Bend, OR;
Status: Other HRR;
Services per beneficiary served, 2000: 2.92;
Services per beneficiary served, 2008: 3.40;
Percentage change in services per beneficiary served, 2000 to 2008:
16.8.
HRR name: Eugene, OR;
Status: Other HRR;
Services per beneficiary served, 2000: 2.89;
Services per beneficiary served, 2008: 3.20;
Percentage change in services per beneficiary served, 2000 to 2008:
10.5.
HRR name: Medford, OR[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.89;
Services per beneficiary served, 2008: 3.21;
Percentage change in services per beneficiary served, 2000 to 2008:
11.1.
HRR name: Portland, OR[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.94;
Services per beneficiary served, 2008: 3.32;
Percentage change in services per beneficiary served, 2000 to 2008:
13.0.
HRR name: Salem, OR;
Status: Other HRR;
Services per beneficiary served, 2000: 2.91;
Services per beneficiary served, 2008: 3.32;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
HRR name: Allentown, PA[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.49;
Services per beneficiary served, 2008: 3.98;
Percentage change in services per beneficiary served, 2000 to 2008:
14.3.
HRR name: Altoona, PA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
13.3.
HRR name: Danville, PA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.42;
Percentage change in services per beneficiary served, 2000 to 2008:
10.8.
HRR name: Erie, PA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.25;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
14.7.
HRR name: Harrisburg, PA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.24;
Services per beneficiary served, 2008: 3.68;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
HRR name: Johnstown, PA;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.31;
Services per beneficiary served, 2008: 3.96;
Percentage change in services per beneficiary served, 2000 to 2008:
19.9.
HRR name: Lancaster, PA;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.33;
Services per beneficiary served, 2008: 3.82;
Percentage change in services per beneficiary served, 2000 to 2008:
14.9.
HRR name: Philadelphia, PA[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.76;
Services per beneficiary served, 2008: 4.35;
Percentage change in services per beneficiary served, 2000 to 2008:
15.6.
HRR name: Pittsburgh, PA[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.72;
Services per beneficiary served, 2008: 4.30;
Percentage change in services per beneficiary served, 2000 to 2008:
15.7.
HRR name: Reading, PA;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.27;
Services per beneficiary served, 2008: 3.86;
Percentage change in services per beneficiary served, 2000 to 2008:
17.9.
HRR name: Sayre, PA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.14;
Services per beneficiary served, 2008: 3.60;
Percentage change in services per beneficiary served, 2000 to 2008:
14.6.
HRR name: Scranton, PA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.46;
Services per beneficiary served, 2008: 3.86;
Percentage change in services per beneficiary served, 2000 to 2008:
11.3.
HRR name: Wilkes-Barre, PA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.47;
Services per beneficiary served, 2008: 3.94;
Percentage change in services per beneficiary served, 2000 to 2008:
13.4.
HRR name: York, PA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.03;
Services per beneficiary served, 2008: 3.51;
Percentage change in services per beneficiary served, 2000 to 2008:
15.9.
HRR name: Providence, RI[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.72;
Percentage change in services per beneficiary served, 2000 to 2008:
13.9.
HRR name: Charleston, SC[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.32;
Services per beneficiary served, 2008: 3.69;
Percentage change in services per beneficiary served, 2000 to 2008:
11.3.
HRR name: Columbia, SC;
Status: Other HRR;
Services per beneficiary served, 2000: 3.22;
Services per beneficiary served, 2008: 3.74;
Percentage change in services per beneficiary served, 2000 to 2008:
15.9.
HRR name: Florence, SC[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.45;
Services per beneficiary served, 2008: 3.77;
Percentage change in services per beneficiary served, 2000 to 2008:
9.3.
HRR name: Greenville, SC;
Status: Other HRR;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.55;
Percentage change in services per beneficiary served, 2000 to 2008:
13.9.
HRR name: Spartanburg, SC[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.07;
Services per beneficiary served, 2008: 3.44;
Percentage change in services per beneficiary served, 2000 to 2008:
12.1.
HRR name: Rapid City, SD[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.12;
Services per beneficiary served, 2008: 3.16;
Percentage change in services per beneficiary served, 2000 to 2008:
1.2.
HRR name: Sioux Falls, SD[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.37;
Percentage change in services per beneficiary served, 2000 to 2008:
9.2.
HRR name: Chattanooga, TN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.40;
Services per beneficiary served, 2008: 3.80;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
HRR name: Jackson, TN;
Status: Other HRR;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.80;
Percentage change in services per beneficiary served, 2000 to 2008:
16.7.
HRR name: Johnson City, TN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.66;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
HRR name: Kingsport, TN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.39;
Percentage change in services per beneficiary served, 2000 to 2008:
11.0.
HRR name: Knoxville, TN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
12.4.
HRR name: Memphis, TN[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.71;
Services per beneficiary served, 2008: 4.23;
Percentage change in services per beneficiary served, 2000 to 2008:
14.2.
HRR name: Nashville, TN[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.71;
Percentage change in services per beneficiary served, 2000 to 2008:
13.1.
HRR name: Abilene, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.62;
Services per beneficiary served, 2008: 3.86;
Percentage change in services per beneficiary served, 2000 to 2008:
6.7.
HRR name: Amarillo, TX[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 3.83;
Percentage change in services per beneficiary served, 2000 to 2008:
9.3.
HRR name: Austin, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.52;
Services per beneficiary served, 2008: 3.88;
Percentage change in services per beneficiary served, 2000 to 2008:
10.2.
HRR name: Beaumont, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.79;
Services per beneficiary served, 2008: 4.20;
Percentage change in services per beneficiary served, 2000 to 2008:
10.9.
HRR name: Bryan, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.49;
Services per beneficiary served, 2008: 3.80;
Percentage change in services per beneficiary served, 2000 to 2008:
9.0.
HRR name: Corpus Christi, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.81;
Services per beneficiary served, 2008: 4.28;
Percentage change in services per beneficiary served, 2000 to 2008:
12.4.
HRR name: Dallas, TX[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.68;
Services per beneficiary served, 2008: 4.11;
Percentage change in services per beneficiary served, 2000 to 2008:
11.7.
HRR name: El Paso, TX[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 3.78;
Percentage change in services per beneficiary served, 2000 to 2008:
7.9.
HRR name: Fort Worth, TX;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.41;
Services per beneficiary served, 2008: 3.93;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
HRR name: Harlingen, TX;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 4.12;
Services per beneficiary served, 2008: 4.74;
Percentage change in services per beneficiary served, 2000 to 2008:
15.1.
HRR name: Houston, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 4.55;
Services per beneficiary served, 2008: 4.67;
Percentage change in services per beneficiary served, 2000 to 2008:
2.6.
HRR name: Longview, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.60;
Services per beneficiary served, 2008: 3.83;
Percentage change in services per beneficiary served, 2000 to 2008:
6.4.
HRR name: Lubbock, TX[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.69;
Services per beneficiary served, 2008: 3.98;
Percentage change in services per beneficiary served, 2000 to 2008:
7.8.
HRR name: McAllen, TX;
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 4.45;
Services per beneficiary served, 2008: 5.11;
Percentage change in services per beneficiary served, 2000 to 2008:
15.0.
HRR name: Odessa, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.65;
Services per beneficiary served, 2008: 3.40;
Percentage change in services per beneficiary served, 2000 to 2008:
-6.9.
HRR name: San Angelo, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.17;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
18.5.
HRR name: San Antonio, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.70;
Services per beneficiary served, 2008: 4.20;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
HRR name: Temple, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.38;
Services per beneficiary served, 2008: 3.47;
Percentage change in services per beneficiary served, 2000 to 2008:
2.5.
HRR name: Tyler, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.70;
Services per beneficiary served, 2008: 3.96;
Percentage change in services per beneficiary served, 2000 to 2008:
6.9.
HRR name: Victoria, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.69;
Services per beneficiary served, 2008: 4.07;
Percentage change in services per beneficiary served, 2000 to 2008:
10.1.
HRR name: Waco, TX;
Status: Other HRR;
Services per beneficiary served, 2000: 3.26;
Services per beneficiary served, 2008: 3.58;
Percentage change in services per beneficiary served, 2000 to 2008:
9.9.
HRR name: Wichita Falls, TX[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.69;
Services per beneficiary served, 2008: 3.99;
Percentage change in services per beneficiary served, 2000 to 2008:
8.1.
HRR name: Ogden, UT;
Status: Other HRR;
Services per beneficiary served, 2000: 2.77;
Services per beneficiary served, 2008: 3.31;
Percentage change in services per beneficiary served, 2000 to 2008:
19.5.
HRR name: Provo, UT;
Status: Other HRR;
Services per beneficiary served, 2000: 2.80;
Services per beneficiary served, 2008: 3.29;
Percentage change in services per beneficiary served, 2000 to 2008:
17.3.
HRR name: Salt Lake City, UT[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.89;
Services per beneficiary served, 2008: 3.20;
Percentage change in services per beneficiary served, 2000 to 2008:
10.8.
HRR name: Burlington, VT[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.05;
Services per beneficiary served, 2008: 3.29;
Percentage change in services per beneficiary served, 2000 to 2008:
8.0.
HRR name: Arlington, VA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.50;
Services per beneficiary served, 2008: 3.91;
Percentage change in services per beneficiary served, 2000 to 2008:
11.7.
HRR name: Charlottesville, VA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.84;
Services per beneficiary served, 2008: 3.20;
Percentage change in services per beneficiary served, 2000 to 2008:
12.4.
HRR name: Lynchburg, VA;
Status: Other HRR;
Services per beneficiary served, 2000: 2.81;
Services per beneficiary served, 2008: 3.33;
Percentage change in services per beneficiary served, 2000 to 2008:
18.4.
HRR name: Newport News, VA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
10.9.
HRR name: Norfolk, VA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.34;
Services per beneficiary served, 2008: 3.75;
Percentage change in services per beneficiary served, 2000 to 2008:
12.5.
HRR name: Richmond, VA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.30;
Services per beneficiary served, 2008: 3.61;
Percentage change in services per beneficiary served, 2000 to 2008:
9.1.
HRR name: Roanoke, VA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.18;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
7.6.
HRR name: Winchester, VA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.10;
Services per beneficiary served, 2008: 3.41;
Percentage change in services per beneficiary served, 2000 to 2008:
9.9.
HRR name: Everett, WA;
Status: Other HRR;
Services per beneficiary served, 2000: 2.95;
Services per beneficiary served, 2008: 3.33;
Percentage change in services per beneficiary served, 2000 to 2008:
12.9.
HRR name: Olympia, WA;
Status: Other HRR;
Services per beneficiary served, 2000: 2.85;
Services per beneficiary served, 2008: 3.30;
Percentage change in services per beneficiary served, 2000 to 2008:
15.7.
HRR name: Seattle, WA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.08;
Services per beneficiary served, 2008: 3.42;
Percentage change in services per beneficiary served, 2000 to 2008:
10.9.
HRR name: Spokane, WA[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.04;
Services per beneficiary served, 2008: 3.40;
Percentage change in services per beneficiary served, 2000 to 2008:
11.9.
HRR name: Tacoma, WA;
Status: Other HRR;
Services per beneficiary served, 2000: 3.04;
Services per beneficiary served, 2008: 3.43;
Percentage change in services per beneficiary served, 2000 to 2008:
12.6.
HRR name: Yakima, WA;
Status: Other HRR;
Services per beneficiary served, 2000: 2.87;
Services per beneficiary served, 2008: 3.23;
Percentage change in services per beneficiary served, 2000 to 2008:
12.5.
HRR name: Charleston, WV[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.38;
Services per beneficiary served, 2008: 3.76;
Percentage change in services per beneficiary served, 2000 to 2008:
11.3.
HRR name: Huntington, WV[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.36;
Services per beneficiary served, 2008: 3.87;
Percentage change in services per beneficiary served, 2000 to 2008:
15.2.
HRR name: Morgantown, WV[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.41;
Services per beneficiary served, 2008: 3.81;
Percentage change in services per beneficiary served, 2000 to 2008:
11.5.
HRR name: Appleton, WI;
Status: Other HRR;
Services per beneficiary served, 2000: 2.88;
Services per beneficiary served, 2008: 3.29;
Percentage change in services per beneficiary served, 2000 to 2008:
14.5.
HRR name: Green Bay, WI[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.02;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
16.6.
HRR name: La Crosse, WI[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.89;
Services per beneficiary served, 2008: 3.19;
Percentage change in services per beneficiary served, 2000 to 2008:
10.6.
HRR name: Madison, WI[A];
Status: Other HRR;
Services per beneficiary served, 2000: 2.94;
Services per beneficiary served, 2008: 3.34;
Percentage change in services per beneficiary served, 2000 to 2008:
13.6.
HRR name: Marshfield, WI;
Status: Other HRR;
Services per beneficiary served, 2000: 3.15;
Services per beneficiary served, 2008: 3.52;
Percentage change in services per beneficiary served, 2000 to 2008:
11.8.
HRR name: Milwaukee, WI[A];
Status: Potentially overserved HRR;
Services per beneficiary served, 2000: 3.28;
Services per beneficiary served, 2008: 3.87;
Percentage change in services per beneficiary served, 2000 to 2008:
18.0.
HRR name: Neenah, WI;
Status: Other HRR;
Services per beneficiary served, 2000: 2.97;
Services per beneficiary served, 2008: 3.37;
Percentage change in services per beneficiary served, 2000 to 2008:
13.7.
HRR name: Wausau, WI[A];
Status: Other HRR;
Services per beneficiary served, 2000: 3.06;
Services per beneficiary served, 2008: 3.65;
Percentage change in services per beneficiary served, 2000 to 2008:
19.4.
HRR name: Casper, WY;
Status: Other HRR;
Services per beneficiary served, 2000: 3.07;
Services per beneficiary served, 2008: 3.47;
Percentage change in services per beneficiary served, 2000 to 2008:
13.1.
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS and HRR data from Dartmouth.
Notes: Potentially overserved HRRs are areas that were in the top half
of HRRs in both utilization of physician services in 2000 and growth in
utilization of physician services from 2000 to 2008. The rest of the
areas were designated as other HRRs. Some HRRs cross state lines.
[A] HRR that crosses state lines.
[End of table]
[End of section]
Appendix VIII: Selected Physician Services in Potentially Overserved
and Other HRRs:
Using BETOS code to which each procedure code in our claims data was
assigned, we reviewed specific categories of physician services.
[Footnote 77] We collapsed data on other services and procedures into
summary categories. We classified HRRs by utilization status.[Footnote
78] Our measure of utilization--services per beneficiary served--is
based on Medicare claims data for services performed in the first 28
days of April 2000 and April 2008. An HRR was designated as potentially
overserved if it was in both the top half of all areas in number of
services per beneficiary served in 2000 and in the top half of the
growth rate in services per beneficiary served from 2000 to 2008. Table
17 shows the specific service categories we reviewed, the change in the
number of services provided per 1,000 FFS beneficiaries from April 2000
to April 2008, and the number of and difference in services provided in
potentially overserved and other HRRs.
Table 17: Selected Physician Services Provided per 1,000 Medicare FFS
Beneficiaries in Potentially Overserved and Other Hospital Referral
Regions:
Service category: All evaluation and management;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 15.2;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 1,243.0;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
944.7;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 31.6.
Service category: Office visits-new patients;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 6.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 35.0;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
28.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 23.0.
Service category: Office visits-established patients;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 14.2;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 572.4;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
472.8;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 21.1.
Service category: Hospital visits;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 28.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 301.5;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
210.9;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 42.9.
Service category: Emergency room visits;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 14.1;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 40.3;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
38.8;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 3.8.
Service category: All imaging;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 41.5;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 461.5;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
385.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 19.7.
Service category: CT scans;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 94.3;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 58.4;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
49.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 18.0.
Service category: MRIs;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 116.5;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 17.0;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
14.8;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 14.8.
Service category: Endoscopy;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 20.9;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 26.4;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
22.2;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 18.8.
Service category: Lab tests;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 548.6;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 45.6;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
34.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 32.4.
Service category: Other tests;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 26.7;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 170.1;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
120.0;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 41.8.
Service category: All major procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: -9.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 24.3;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
22.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 8.0.
Service category: Major cardiac procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: -22.9;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 12.3;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
10.5;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 16.9.
Service category: Major orthopedic procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 25.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 3.9;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008: 4.1;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: -6.0.
Service category: Minor procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 37.4;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 211.4;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
130.2;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 62.4.
Service category: Ambulatory procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 73.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 68.5;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
51.2;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 33.7.
Service category: Eye procedures;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 28.5;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 13.4;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
12.0;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 11.4.
Service category: Anesthesia;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 16.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 22.4;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
16.6;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 35.0.
Service category: Oncology;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 10.3;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 33.9;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
26.7;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 27.2.
Service category: All services;
Percentage change from 2000 to 2008 in services per 1,000 Medicare FFS
beneficiaries: 25.8;
Services per 1,000 Medicare FFS beneficiaries in potentially overserved
HRRs, 2008: 2,340.8;
Services per 1,000 Medicare FFS beneficiaries in other HRRs, 2008:
1,782.4;
Percentage difference in services per 1,000 Medicare FFS beneficiaries
in potentially overserved and other HRRs, 2008: 31.3.
Source: GAO analysis of Medicare Part B claims and enrollment data from
CMS and HRR data from Dartmouth.
Notes: Potentially overserved HRRs are areas that were in the top half
of HRRs in both utilization of physician services in 2000 and growth in
utilization of physician services from 2000 to 2008. The rest of the
HRRs were designated as other HRRs. Some HRRs cross state lines.
[End of table]
[End of section]
Appendix IX: Comments from the Centers for Medicare & Medicaid
Services:
Department Of Health & Human Services:
Office Of The Secretary
Assistant Secretary for Legislation:
Washington, DC 20201:
AUGust 6, 2009:
A. Bruce Steinwald:
Director, Health Care:
Government Accountability Office:
441 G Street NW:
Washington, DC 20548
Dear Mr. Steinwald:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) draft report entitled: "Medicare
Physician Services: Utilization Trends Indicate Sustained Beneficiary
Access with High and Growing Levels of Service in Some Areas of the
Nation (GAO-09-559).
The Department appreciates the opportunity to review and comment on
this report before its publication.
Sincerely,
Signed by:
Barbara Pisaro Clark:
Acting Assistant Secretary for Legislation:
Attachment:
[End of letter]
Department Of Health & Human Services:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
DATE: August 6, 2009:
T0: Barbara Pisaro Clark:
Assistant Secretary of Legislation:
From: [Signed by] Charlene Frizzera:
Acting Administrator:
Subject: Government Accountability Office's Draft Report: "Medicare
Physician Services: Utilization Trends Indicate Sustained Beneficiary
Access with High and Growing Levels of Service in Some Areas of the
Nation" (GAO-09-559):
The Centers for Medicare & Medicaid Services (CMS) appreciates the
opportunity to review and comment on the Government Accountability
Office's (GAO) draft report entitled "Medicare Physician Services:
Utilization Trends Indicate Sustained Beneficiary Access with High and
Growing Levels of Service in Some Areas of the Nation."
The CMS has a longstanding practice of monitoring the effect of policy
changes on beneficiary access to Medicare services. The subject report
will help in this effort.
This GAO study found that Medicare beneficiaries continue to experience
few problems accessing physicians' services during their period of
study. Less than 3 percent reported any major difficulties in accessing
medical care in 2007 and 2008. This finding is consistent with findings
in previous GAO studies released in 2005 and 2006, as well as the
findings contained in Medicare Payment Advisory Commission's February
2009 Report to Congress. Moreover, the data from the GAO studies
consistently show that beneficiary utilization of physicians' services
and physicians' willingness to serve the Medicare population and to
accept Medicare payment rates as payment in full for their services has
risen steadily from 2000 to 2008.
The GAO also found significant geographic variations in beneficiary use
of physicians' services and that the rate of spending growth for
physicians' services also varies geographically. The potentially
overserved areas tended to be the more densely populated urban areas
and areas east of the Mississippi. Beneficiaries in these potentially
overserved areas are similar in demographic characteristics to those in
other areas, which suggests that physicians employ different practice
patterns in different areas of the country.
The GAO notes that the Medicare sustainable growth rate (SGR), which is
used to help control spending on physicians' services, does not account
for these geographic differences in utilization rates. The report
suggests that as Congress continues to consider options for revising
the SGR and other payment reforms that these geographic differences in
utilization and practice patterns will likely continue to be part of
the discussion. The CMS appreciates GAO's analysis on beneficiary
access to physicians' services.
[End of section]
Appendix X: GAO Contact and Staff Acknowledgments:
GAO Contact:
A. Bruce Steinwald, (202) 512-7114 or steinwalda@gao.gov:
Acknowledgments:
In addition to the contact named above, Jessica Farb, Assistant
Director; Todd Anderson; Krister Friday; Jenny Grover; Jessica T. Lee;
Richard Lipinski; and Sarabeth Zemel made major contributions to this
report.
[End of section]
Footnotes:
[1] Medicare is the federally financed health insurance program for
persons aged 65 and over, certain individuals with disabilities, and
individuals with end-stage renal disease. Eligible individuals are
automatically covered by Medicare Part A, which covers hospital and
other inpatient stays. Medicare Part B is optional insurance and covers
hospital outpatient, physician, and other services. Medicare Parts A
and B are known as traditional Medicare or Medicare fee-for-service.
[2] The Boards of Trustees of the Federal Hospital Insurance and
Federal Supplementary Medical Insurance Trust Funds, 2009 Annual Report
of the Boards of Trustees of the Federal Hospital Insurance and Federal
Supplementary Medical Insurance Trust Funds (Washington, D.C., May 12,
2009), and 2008 Annual Report of the Boards of Trustees of the Federal
Hospital Insurance and Federal Supplementary Medical Insurance Trust
Funds (Washington, D.C., Mar. 25, 2008).
[3] The Medicare Improvements for Patients and Providers Act of 2008
canceled a 10.6 percent reduction in Medicare's payments for physician
services that was scheduled to go into effect on July 1, 2008. Pub. L.
No. 110-275, § 131,122 Stat. 2494, 2520. The act froze physician
payment rates for the remainder of 2008 and increased them by 1.1
percent in January 2009. The Congressional Budget Office estimated that
when payment rates are again determined by the SGR in 2010, Medicare
payments for physician services will be reduced by 21 percent.
Congressional Budget Office Cost Estimate, H.R. 6331 Medicare
Improvements for Patients and Providers Act of 2008 (Washington, D.C.,
July 23, 2008).
[4] GAO, Medicare Fee-for-Service Beneficiary Access to Physician
Services: Trends in Utilization of Services, 2000 to 2002, [hyperlink,
http://www.gao.gov/products/GAO-05-145R] (Washington, D.C.: Jan. 12,
2005).
[5] GAO, Medicare Physician Services: Use of Services Increasing
Nationwide and Relatively Few Beneficiaries Report Major Access
Problems, [hyperlink, http://www.gao.gov/products/GAO-06-704]
(Washington, D.C.: July 21, 2006).
[6] Elliott S. Fisher et al., "The Implications of Regional Variations
in Medicare Spending. Part 1: The Content, Quality, and Accessibility
of Care," Annals of Internal Medicine, vol. 138, no. 4 (2003): 273-287,
and Elliott S. Fisher et al., "The Implications of Regional Variations
in Medicare Spending. Part 2: Health Outcomes and Satisfaction with
Care," Annals of Internal Medicine, vol. 138, no. 4 (2003): 288-298.
[7] Fisher et al., "The Implications of Regional Variations in Medicare
Spending. Part 1: The Content, Quality, and Accessibility of Care";
Fisher et al., "The Implications of Regional Variations in Medicare
Spending. Part 2: Health Outcomes and Satisfaction with Care"; Elliott
S. Fisher and H. Gilbert Welch, "Avoiding the Unintended Consequences
of Growth in Medical Care: How Might More Be Worse?" Journal of the
American Medical Association, vol. 281, no. 5 (1999): 446-453; and
Joseph P. Newhouse and The Insurance Experiment Group, Free for All?
Lessons from the RAND Health Insurance Experiment (Cambridge, Mass.:
Harvard University Press, 1993).
[8] We used only CAHPS survey data from Medicare FFS beneficiaries.
[9] We examined over 60 million claims for the first 28 days of April
of each year. These claims represent an annual snapshot of beneficiary
access to physician services for each of the 9 years. Physician fee
updates generally occur at the beginning of each calendar year and
remain constant throughout the year. We selected April to allow time
for the annual fee updates to be implemented beginning January 1, and
for physician behavior to adjust to the new fees. To avoid "calendar
bias"--that is, the occurrence of more weekdays in April in one year
compared to another--and to create an equal number of weekdays in each
year's data set, we limited each year's claims to services performed
within the first 28 days of the month.
[10] 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.
[11] We excluded beneficiaries in Guam, Puerto Rico, and the U.S.
Virgin Islands.
[12] 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.
[13] U.S. Senator Max Baucus, Call to Action: Health Care Reform 2009
(Washington, D.C., Nov. 12, 2008), and Congressional Budget Office,
Factors Underlying the Growth in Medicare's Spending for Physician
Services (Washington, D.C., June 2007).
[14] We referenced counties to metropolitan statistical areas and
metropolitan divisions using U.S. Census Bureau data from the Missouri
Census Data Center.
[15] We excluded four counties with low populations because they lacked
data on Medicare enrollment or utilization of physician services.
[16] By labeling areas as "potentially overserved" and "other," we do
not suggest that the level of care in the other areas is uniformly
appropriate. For example, the level of services provided in the Los
Angeles-Long Beach-Glendale metropolitan division (see table 12 in
appendix III) was among the highest in the nation in both 2000 and
2008. However, because the growth rate was below average in this area,
it did not meet our criteria for being placed in the potentially
overserved category.
[17] In addition, we analyzed the number of services per beneficiary
who received services in April 2000 and April 2008 in Medicare's 87
physician payment localities and in the 306 hospital referral regions
as defined by the Dartmouth Atlas Project. We ranked the two area types
by their level of utilization in 2000 and the change in utilization
from 2000 to 2008. We then designated Medicare physician payment
localities and hospital referral regions in the top half of both
measures as "potentially overserved" and the rest of the Medicare
physician payment localities and hospital referral regions as "other."
For more information on the rank of each Medicare physician payment
locality, see appendix V, and for more information on the rank of each
hospital referral region, see appendix VII.
[18] We were not able to construct variables to exhaustively examine
all of the potential drivers of health care utilization. For example,
we were not able to construct a variable to measure the prevalence of
coordinated care in an area using either data on managed care
penetration or the number of physician group practices in an area.
[19] To account for different levels of urbanization between
potentially overserved and other areas, we adjusted the other areas
group to reflect the same urban/rural composition as the potentially
overserved group.
[20] In addition, we analyzed the utilization of specific services in
April 2008 in potentially overserved and other Medicare physician
payment localities and in potentially overserved and other hospital
referral regions as defined by the Dartmouth Atlas Project. For more
information on the difference in utilization of these services between
potentially overserved and other Medicare physician payment localities,
see appendix VI, and for more information on the difference in
utilization of these services between potentially overserved and other
hospital referral regions, see appendix VIII.
[21] There is a separate anesthesia services conversion factor that is
updated each year.
[22] 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.
[23] Specifically, nonparticipating physicians who do not accept
assignment can charge up to 15 percent above the reduced Medicare-
approved amount and thus receive approximately 109 percent of the
Medicare-approved fee for that service--this amount is known as the
limiting charge. The beneficiary typically has to pay the
nonparticipating physician the full amount of the limiting charge, and
Medicare reimburses the beneficiary for 80 percent of the reduced
Medicare-approved amount.
[24] Physicians may "opt out" of the Medicare program altogether and
charge any amount for the services they provide, but they must inform
beneficiaries in advance of this arrangement. Under this option,
physicians must agree not to file any Medicare claims for 2 years, and
their patients are responsible for 100 percent of the charges. Since
1998, relatively few physicians--approximately 8,300 at the end of
2008--have opted out of the Medicare program.
[25] MedPAC was established by the Balanced Budget Act of 1997, Pub. L.
No. 105-33 § 4022, 111 Stat. 251, 350, 42 U.S.C. § 1395b-6 (2000), to
advise Congress on issues affecting the Medicare program.
[26] Medicare Payment Advisory Commission, Report to the Congress:
Medicare Payment Policy (Washington, D.C., March 2009); Center for
Studying Health System Change as cited by MedPAC; Karen Davis, et al.,
"Meeting Enrollees' Needs: How Do Medicare and Employer Coverage Stack
Up?" Health Affairs, vol. 28, no. 4 (published online May 12, 2009);
and AARP, Access to Physicians Survey (Washington: D.C., February
2007).
[27] U.S. Senate, Committee on Finance, Transforming the Health Care
Delivery System: Proposals to Improve Patient Care and Reduce Health
Care Costs (Washington, D.C., Apr. 29, 2009), [hyperlink,
http://www.finance.senate.gov/sitepages/leg/LEG%202009/042809%20_Health%
20Care%20Description%20of%20Policy%20Option.pdf] (accessed June 3,
2009).
[28] Congressional Budget Office, Geographic Variation in Health Care
Spending (Washington, D.C., February 2008).
[29] John E. Wennberg et al., "Geography and the Debate Over Medicare
Reform," Health Affairs, Web exclusive (Feb. 13, 2002): W96-W114.
[30] Elliott S. Fisher et al., "Slowing the Growth of Health Care
Costs--Lessons from Regional Variation," New England Journal of
Medicine, vol. 360, no. 9 (2009): 849-852.
[31] B. Sirovich, et al., "Discretionary Decision Making by Primary
Care Physicians and the Cost of U.S. Health Care," Health Affairs, vol.
27, no. 3 (2008): 813-23. Using a survey of about 800 primary care
physicians, this study found that compared with those in areas with the
lowest quintile of spending, physicians practicing in areas with the
highest quintile of spending would recommend the following additional
services each year per 100 patients in each clinical category: 80
hypertension follow-up visits, 14 spiral computed tomography scans, 25
echocardiograms, 24 cardiac care unit admissions, and 29
gastroenterology referrals.
[32] "How Much Do We Know?" BMJ Clinical Evidence, [hyperlink,
http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp] (accessed
Apr. 24, 2009).
[33] Pub. L. No. 109-171, § 5104(c), 120 Stat. 4, 40 (2006).
[34] Medicare Payment Advisory Commission, Report to the Congress:
Assessing Alternatives to the Sustainable Growth Rate System
(Washington, D.C., March 2007).
[35] Baucus, Reforming America's Health Care System: A Call to Action.
[36] Using OMB's system for defining MSAs, we classified the nation's
counties as urban or rural. We consolidated the urban counties and
rural counties in each state and the District of Columbia, creating 99
geographic areas. There were 51 urban areas and 48 rural areas. There
were no rural areas in New Jersey, Rhode Island, and the District of
Columbia.
[37] Peter Cunningham and Jack Hadley, "Expanding Care Versus Expanding
Coverage: How To Improve Access To Care," Health Affairs, vol. 23, no.
4 (2004), and Medicare Payment Advisory Commission, Report to the
Congress: Medicare Payment Policy, 93.
[38] These values are based on a count of unique physician
identification numbers (UPIN) on Medicare Part B claims for physicians
who performed services. As part of its transition to using the National
Provider Identifier, in May 2007 CMS stopped issuing UPINs for
physicians billing Medicare for the first time. Therefore, we were
unable to obtain a comparable count of UPINs for 2008.
[39] Medicare beneficiaries may choose how they receive services
covered under Parts A and B. Most beneficiaries receive services
through Medicare's traditional FFS option and can obtain care from any
licensed provider willing to accept Medicare patients. Beneficiaries
can also enroll in the Medicare Advantage program, in which private
health plans generally contract with providers to serve Medicare
beneficiaries.
[40] Physicians may decide on an annual basis whether they will be
Medicare participating physicians.
[41] In our analysis, we grouped small MSAs--that is, MSAs with fewer
than 200,000 residents--together within the same state. Counties
outside of metropolitan divisions and MSAs were designated as rural
areas and were similarly grouped together.
[42] We defined Arkansas, Iowa, Louisiana, Minnesota, Missouri, and all
states to their west as "west of the Mississippi River."
[43] Certain U.S. Census Bureau metropolitan divisions crossed state
lines. In our analysis, we subdivided these entities into areas within
states.
[44] By labeling areas as "potentially overserved" and "other," we do
not suggest that the level of care in the other areas is uniformly
appropriate. For example, the level of services provided in the Los
Angeles-Long Beach-Glendale metropolitan division (see table 12 in
appendix III) was among the highest in the nation in both 2000 and
2008. However, because the growth rate was below the national median in
this area, it did not meet our criteria for being placed in the
potentially overserved category.
[45] See appendix V for more information on potentially overserved and
other Medicare physician payment localities and appendix VII for more
information on potentially overserved and other hospital referral
regions.
[46] The risk scores are based on the demographics and diagnoses of the
entire FFS population in a county and reflect the likelihood of needing
more expensive care for Medicare Parts A and B combined. The population
we used to determine whether an area is potentially overserved consists
of beneficiaries who received Part B physician services in April 2000
or April 2008.
[47] In the potentially overserved areas, 22.9 percent of the 2006
population attained at least 4 years of college education, compared to
25.5 percent in other areas.
[48] Newhouse et al., Free for All? Lessons from the RAND Health
Insurance Experiment.
[49] The view that health care supply creates its own demand is
sometimes referred to as Roemer's Law. M.I. Roemer and M. Shain,
Hospital Utilization Under Insurance, Hospital Monograph Series No. 6
(Chicago: American Hospital Association, 1959); Fisher et al., "The
Implications of Regional Variations in Medicare Spending. Part 1: The
Content, Quality, and Accessibility of Care," 273-287; Fisher et al.,
"The Implications of Regional Variations in Medicare Spending. Part 2:
Health Outcomes and Satisfaction with Care," 288-298; and E.S. Fisher,
J.E. Wennberg, T.A. Stukel, and S.M. Sharp, "Hospital Readmission Rates
for Cohorts of Medicare Beneficiaries in Boston and New Haven," New
England Journal of Medicine, vol. 331, no.15 (1994): 989-995.
[50] K. Baicker and A. Chandra, "Medicare Spending, the Physician
Workforce, and Beneficiaries' Quality of Care," Health Affairs, Web
exclusive (Apr. 7, 2004): 184-197, and B. Starfield, L. Shi, and J.
Macinko, "Contribution of Primary Care to Health Systems and Health,"
The Milbank Quarterly, vol. 83, no. 3 (2005): 457-502.
[51] John E. Wennberg et al., Tracking the Care of Patients with Severe
Chronic Illness: Dartmouth Atlas of Health Care 2008 (Lebanon, N.H.:
2008); Fisher et al., "The Implications of Regional Variations in
Medicare Spending. Part 1: The Content, Quality, and Accessibility of
Care," 273-287; and Fisher et al., "The Implications of Regional
Variations in Medicare Spending. Part 2: Health Outcomes and
Satisfaction with Care," 288-298.
[52] Floyd J. Fowler, Jr., et al., "Relationship Between Regional Per
Capita Medicare Expenditures and Patient Perceptions of Quality of
Care," Journal of the American Medical Association, vol. 299, no. 20
(2008): 2406-2412; Fisher et al., "The Implications of Regional
Variations in Medicare Spending. Part 1: The Content, Quality, and
Accessibility of Care," 273-287; and Fisher et al., "The Implications
of Regional Variations in Medicare Spending. Part 2: Health Outcomes
and Satisfaction with Care," 288-298.
[53] See appendix VI for trends in selected physician services in
potentially overserved and other Medicare physician payment localities
and appendix VIII for trends in selected physician services in
potentially overserved and other hospital referral regions.
[54] Wennberg et al., Tracking the Care of Patients with Severe Chronic
Illness: Dartmouth Atlas of Health Care 2008; E.S. Fisher and J.E.
Wennberg, "Health Care Quality, Geographic Variations, and the
Challenge of Supply-Sensitive Care," Perspectives in Biology and
Medicine, vol. 46, no. 1, (Winter 2003): 69-79; Center for the
Evaluative Clinical Sciences, Dartmouth Atlas Project Topic Brief:
Effective Care (Lebanon, N.H.: 2007); Center for the Evaluative
Clinical Sciences, Dartmouth Atlas Project Topic Brief: Preference-
Sensitive Care (Lebanon, N.H.: 2007); Center for the Evaluative
Clinical Sciences, Dartmouth Atlas Project Topic Brief: Supply-
Sensitive Care (Lebanon, N.H.: 2007); and RAND, Assessing the
Appropriateness of Care: How Much Is Too Much? (1998).
[55] Imaging and diagnostic tests are examples of supply-sensitive
care, a term used by the Dartmouth Atlas of Health Care to mean care
for which the supply of resources partially determines the frequency of
use.
[56] Dartmouth researchers have identified knee replacements as an
example of preference-sensitive care, meaning interventions for which
there is a choice between at least two treatments that have different
risks and benefits. Treatment choices among preference-sensitive care
depend on patient preference and, often, physician discretion.
[57] Medicare is the federally financed health insurance program for
persons aged 65 and over, certain individuals with disabilities, and
individuals with end-stage renal disease. Eligible individuals are
automatically covered by Medicare Part A, which covers hospital and
other inpatient stays. Medicare Part B is optional insurance and covers
hospital outpatient, physician, and other services. Medicare Parts A
and B are known as traditional Medicare or Medicare FFS.
[58] We analyzed the CAHPS survey of FFS beneficiaries, including
respondents with and without Part D coverage.
[59] According to CMS officials, fewer beneficiaries were surveyed in
2008 because of resource limitations.
[60] We excluded claims for services provided by nurse practitioners,
physician assistants, and other nonphysician practitioners. We included
services covered by the fee schedule--such as office visits, major and
minor surgeries, and imaging services--as well as anesthesia services.
We identified claims for physician services covered by the fee schedule
by limiting the files to include only Healthcare Common Procedure Codes
that are on the physician fee schedule and covered by Medicare. We
excluded claims from beneficiaries in Guam, Puerto Rico, and the U.S.
Virgin Islands.
[61] 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.
[62] We chose September so our data would include up to two quarters of
processed claims from April of each year. This equates to about 95
percent of the claims for services provided in April of each year.
[63] There are no rural counties in Rhode Island, New Jersey, and the
District of Columbia.
[64] These values are based on a count of unique physician
identification numbers (UPIN) on Medicare FFS claims for physicians who
performed services. As part of its transition to using the National
Provider Identifier, in May 2007 CMS stopped issuing UPINs for
physicians billing Medicare for the first time.
[65] Physicians who "accept assignment" are those who agree to accept
Medicare's fee as payment in full. The fee includes the coinsurance
amount (usually 20 percent) paid by the beneficiary. Participating
physicians must accept assignment for all Medicare-covered services
that they provide to beneficiaries.
[66] We referenced counties to MSAs and metropolitan divisions using
U.S. Census Bureau data from the Missouri Census Data Center.
[67] We excluded four counties with low populations because they lacked
data on Medicare enrollment or utilization of physician services.
[68] We also analyzed utilization of physician services in Medicare's
87 physician payment localities and in the 306 hospital referral
regions (HRR) as defined by the Dartmouth Atlas Project. We combined
certain Medicare physician payment localities in California, Kansas,
and Missouri. We ranked both the Medicare physician payment localities
and the HRRs by their level of utilization in 2000 and their change in
utilization from 2000 to 2008. To determine the utilization status of
either a Medicare physician payment locality or an HRR, we designated
areas in the top half of both measures as "potentially overserved" and
the rest as "other" areas.
[69] We were not able to obtain data to account for all the factors
that might explain differences in utilization. For example, we were
unable to find sufficient data to measure the level of coordinated care
across all areas.
[70] Risk scores are based on the demographics and diagnoses of the
entire FFS population in a county and reflect the likelihood of greater
combined Medicare Part A and Part B expenditures. Geographic area risk
scores are the population-weighted average of risk scores for the
counties within an area.
[71] Using the BETOS codes, we also compared the utilization of
specific types of physician services in potentially overserved and
other Medicare physician payment localities and in potentially
overserved and other HRRs.
[72] In order to ensure the consistency of individuals' responses to
both the question on the need for care and the related access question,
we used recoded survey responses. For example, if an individual
answered in a prior question that he or she did not need a specialist,
the recoded response on the access question related to specialists was
"not applicable."
[73] According to CMS, the BETOS coding system consists of readily
understood clinical categories, is stable over time, and is relatively
immune to minor changes in technology or practice patterns.
[74] There are 89 Medicare physician payment localities across the
United States and surrounding territories. We excluded the Medicare
physician payment localities for the U.S. Virgin Islands and Puerto
Rico from our analysis.
[75] According to CMS, the BETOS coding system consists of readily
understood clinical categories, is stable over time, and is relatively
immune to minor changes in technology or practice patterns.
[76] Physician payment localities are the 87 distinct geographic
regions designated by Medicare among which physician payments are
adjusted for the costs of operating a private medical practice in each
locality.
[77] According to CMS, the BETOS coding system consists of readily
understood clinical categories, is stable over time, and is relatively
immune to minor changes in technology or practice patterns.
[78] HRRs are the 306 distinct geographic regions designated by
Dartmouth researchers to represent regional health care markets for
tertiary medical care. Each HRR contains at least one hospital that
performs major cardiovascular procedures and neurosurgery.
[End of section]
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