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OCR for page 178
9
Health Services Utilization
INTRODUCTION
The amount and types of health care services used by older adults
is influenced by many factors. Although the need for health services
and the frequency and intensity of service utilization are clearly
related to health status and level of impairment or disability, many
factors unrelated to health needs per se also play important roles.
Among these are public policies that specify the types of services
and providers covered by public funds, cost-sharing provisions, the
supply of alternative sources and types of care; living arrangements
and access to informal care; the availability of adequate numbers of
trained personnel; advances or changes in health care technology and
delivery systems; and the attitudes and values of potential recipients
and providers of care.
The issues involved are shaped largely by public policies dealt
with previously in the discussions of long-term care in Chapter 7
and the financing of health care services for the elderly in Chapter
8. The questions that follow recast many of those raised earlier
to sharpen consideration of requirements for policy-relevant data
on health services for the elderly generally, i.e., those who receive
episodic care as well as those who are in need of long-term care. Major
policy issues that need to be addressed through special research and
demonstration programs are listed first and these are followed by
questions that are clearly related and should be answerable through
information systems.
178
OCR for page 179
HEALTH SERVICES UTILIZATION
.
.
.
179
How do benefit provisions and cost sharing under Medicare,
including the deductibles, affect the rates of use of different
types of health services and providers?
What gaps in Medicare are being filled by supplemental pri-
vate health insurance; how widespread is this type of coverage;
and what effect does such coverage have on the utilization of
health services?
How does the supply of alternative sources and types of care
influence the use of health services; what sectors of health
care are most affected now; how will trends toward increased
home care, adult day care programs, and other alternative
types of services alter levels and patterns of utilization of
health services?
How are the content, type, and place of care affected by
the use of physicians and allied health personnel trained in
gerontology? How wiD future requirements for health care
resources be affected by the increased availability of such
personnel now being projected?
To what extent are advances in diagnostic and therapeutic
health care technology reaching the elderly; how are they ad
fecting utilization of health services subsequent to treatment;
what is the role of government in determining appropriate
access of the elderly to health care technology established as
cost-effective?
How are changes in the structure of health care systems and
reimbursement arrangements, e.g., capitation payments to
HMOs and preferred provider organizations influencing the
patterns of health care utilization; how effective are these
changes in meeting health care needs of the elderly?oWhat is
the effect of changes in benefits, cost sharing, and other cost-
containment measures, such as prospective payment systems
(e.g., diagnosis-related group in the hospital), on rates and
sources of care used, and how rapidly do these changes occur?
Need for Services
Need can be viewed from two vantage points, that of the provider
and that of the consumer. In the former instance, what is often
meant by need is the health care expert's view of requirements for
primary or secondary prevention of disease, diagnosis, treatment,
or rehabilitation in the presence of specified signs, symptoms, or
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180
AGING POPULATION IN THE TWENTY-FIRST CENTURY
conditions. Recourse to health services is expected to result in some
benefit to the patient, the degree of certainty of benefit varying with
knowledge of natural history of the condition and the availability of
interventions that are effective at different stages of the condition.
Furthermore, agreement may be greater on whether care should be
obtained than on the nature, source, or volume of care required (or its
outcome). Nevertheless, standards exist for certain types of services,
as reflected by the prospective payment system for hospital care as
wed as for treatment of specific conditions such as hypertension and
other chronic conditions.
From the consumer's standpoint, the concern is with a complex
set of perceptions, values, and other factors that facilitate or create
barriers to health services. The end point is the observed utilization
of services and care identified by the consumer as needed but not
obtained. This is independent of the provider's appraisal of the
appropriateness of the care sought.
Of interest is the repeated observation that older persons on
average tend to view their health positively, although less often, than
younger persons. Responses to the 1982 National Health Interview
Survey indicate that some 65 percent of elderly persons living in the
community viewed their health as good to excellent when compared
to others of their own age; and only 35 percent reported their health
as fair or poor (U.S. Congress, Senate, 1986a). This information is
subject to a variety of interpretations, but self-assessed or perceived
health status is associated with the use of health care services as
measured, for instance, by rates of physician utilization (Crazier,
1985; Waldo and Lazenby, 1984~.
Clearly, the extent to which the elderly use the formal health
care system, including noninstitutional and short- and long-term
institutional care, is related to the level and complexity of their
medical needs, which, on average, increase with age. Those with
manifest disability tend to make the most intensive use of health
care service (Lubitz and Prihoda, 1984~. Utilization rates tend to be
highest during the last year or two of life (Lubitz and Prihoda, 1984;
Gornick et al., 1985), and for some types of services, e.g., hospital and
nursing home care, they are far greater among the oldest-old than
among those ages 65-74 (U.S. Congress, Senate, 1986a; National
Center for Health Statistics, 1981~.
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HEALTH SERVICES UTILIZATION
181
Impact of Public Policies
There is no question that increased access to care afforded the
elderly by the Medicare and Medicaid programs enacted in 1965 has
had a large impact on the use of health care services by the elderly,
both as regards the types of services consumed and the frequency and
intensity of service utilization. Rates of hospital and nursing home
use by the elderly, for example, increased substantially between the
late 1960s and the late 1970s (Rice and Feldman, 1983; Gornick et
al., 1985~. Much of the increase in service utilization of hospitals,
skilled and intermediate care nursing facilities, home health care, and
physicians' services, for instance, has been attributed to previously
unmet needs (Rabin, 1985~. Changes in coverage provisions and re-
imbursement rates, for both the federal Medicare program and the
federaI-state Medicaid program, are likely to affect future utilization
patterns, as well as the providers of care, as they have in the past
(see Chapter 8~. The Medicaid program already varies considerably
among states since the states have significant flexibility in deter-
mining eligibility for assistance, the scope of benefits provided, and
reimbursement rates for these services. This verification may well
increase as states attempt to curtail costs with differential effects on
access to medical care on the part of the poor, including the poor
elderly. Medicare coverage for services provided to the elderly by
HMOs and other capitated plans can be expected to affect the types
of services consumed by the elderly as well as their mode of provision.
The federally initiated DRG system for reimbursing hospitals for the
care they provide to the elderly under Medicare, as well as the fed-
erally encouraged increasing use of prospective payment system for
health care generally, are other major policy changes that affect the
demand and supply of services available to the elderly. (For an anal-
ysis of the potential impact of hospital DRGs on access to inpatient
hospital and other types of care by the elderly and vulnerable elderly
groups such as the frail, disabled, alcoholic, poor, and mentally ill,
see Office of Technology Assessment, 1985a).
Federal policies affect both the supply and training of geriatric
manpower, which has Implications for service availability and uti-
l~zation. At the state level, certificate of need (CON) requirements
for authorization to build or expand hospitals and nursing homes
can greatly constrict or enhance the supply of services available to
meet the needs of the elderly, and thus affect service utilization. The
supply of nursing home beds available to impaired elderly and other
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182
AGING POPULATIONIN THE TWENTY-FIRST CENTURY
disabled persons is determined in part by state CON policies (Feder
and ScanIon, 1980~.
Supply of Alternative Sources and Awes of Care
The availability of substitute, or alternative types of health care
services or facilities for persons with particular health needs or limita-
tions in function affects the utilization of these services and facilities
in complex and incompletely understood ways. The chronic care
needs of the moderately impaired elderly assistance with activities
of daily living or instrumental activities of daily living, for example-
in contrast to their strictly medical care needs, can be met in a variety
of settings. These settings include intermediate care nursing facili-
ties, retirement communities, adult day care centers or programs, or
the home with the assistance of family members or with community-
provided services such as meals-on-wheels and visiting nurses. The
extent to which each or arty of these types of services or support
systems will be used by an individual or group of persons similarly
disabled depends in part on their availability within the community,
in part on the ease of access to these and other kinds of arrangements,
and in part on the financing mechanisms.
Care for the acutely ill as well may be provided in more than
one setting or type of facility in a hospital as an inpatient (as is
typical), in a hospital as an outpatient, in a skilled nursing facility,
in a physician's office, or in the home-depending on the availability
of these different sources of care, the wishes of the individual and
family, and financial factors and insurance coverage.
Diving Arrangements and Accese to Informal Care
Living arrangements and access to informal care provided by
relatives or friends also affect the demand for formal health care and
health-related services. A recent study found that elderly people
living alone were at greater risk of institutionalization than compa-
rably disabled people of the same age living with one or more other
persons after controlling for variables such as age, medical status,
and functional status (Branch and Jette, 1982~. For example, elderly
persons who are married and/or live with or near adult relatives-
particularly their adult children are less likely to be consumers of
formal health services than those who live alone. "At any level of
need, the probability of formal service is lowest for those elderly
OCR for page 183
HEALTH SERVICES UTILIZATION
183
who live with either spouses or other relatives" (Soldo and Manton,
1985:306~. The family clearly plays an important role as determiner
of service needs, finders of services, and brokers for its elderly rela-
tives.
Demographic trends will influence the availability of informal
sources of care for the elderly. Future cohorts of U.S. elderly persons
will be larger than the present cohort, and the greatest increase in
size and percentage of the entire U.S. population will occur among
the oldest old. As the population ages, successive cohorts of potential
informal caregivers, such as spouses or adult children of ill or impaired
elderly people, will be older as well and possibly less able to care for
their elderly relatives because of their own health limitations. In
addition, families are having fewer children and, as discussed in
Chapter 2, the number of elderly women living alone is increasing
rapidly.
Availability of Trained Performer
Utilization of health services by the elderly who have particular
combinations of medical problems is affected by the availability of
health and medical care personnel who are trained to meet the health
care needs unique to the elderly population. Increasingly, questions
are being raised about the quality of care provided to the elderly by
both primary care providers and specialists, in both institutional and
noninstitutional settings (Kane et al., 1980; Institute of Medicine,
1986~. Moreover, the diagnosis and management of diseases and
illnesses common among older adults, such as Alzheimer's disease,
require special training in geriatrics. While information on current
numbers of appropriately trained personnel is limited (National Insti-
tute on Aging, 1984b), most sources concur that inadequate attention
has been paid to ensuring an adequate supply of trained practition-
ers, including generalists, specialists, and academics, to provide care
to the elderly and to advance the knowledge base (see, for example,
National Institute on Aging, 1984b; National Institute on Aging,
1985; Minaker and Rowe, 1985~. Projected increases in the elderly
population, particularly among those age 75 and over, reinforce the
need to attend to the personnel and training issue.
Technological Advances or Changes
Utilization of health services by the elderly is also affected by
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184
HI GINO POPULATION IN THE TWENTY-FIRST CENTURY
the introduction, availability, and diffusion of new medical technolo-
gies, including techniques, drugs, equipment, and procedures used
by health care personnel in prevention, diagnosis and screening,
treatment, or rehabilitation (see Young, 1985~. The development
and availability of CT (computed tomography) scanning and NMR
(nuclear magnetic resonance) for the detection of tumors, cardiac
pacemaker implant surgery, coronary artery bypass surgery to re-
lieve angina pectoris, and hip arthroplasty (total hip replacement)
are examples of technological innovations and procedures that have
grown rapidly in recent years. Cataract surgery with lens implant,
coronary artery bypass surgery, and hip arthroplasty are surgical
procedures that were relatively new in 1972 but whose use increased
rapidly for people age 65 and over between 1972 and 1981. For ex-
ample, from 1972 to 1981, hip arthroplasties increased in number by
244 percent for people age 65 and over, and 509 percent for those
age 74 and over. And by 1981, an estimated 250,000 people age 65
and over had a lens implant a rare procedure in 1972 (Valvona and
Sloan, 1985~.
Attitudes and Values of Potential Recipients and Providers of Care
Attitudes regarding formal caregivers and the perceived value
of formal health care services by older adults affect health care uti-
lization rates. Of major importance are perceptions and attitudes
concerning the nature of an "illness," which may be very different
from the medically defined "disease" diagnosed within the health
care setting. For example, the consumption of mental health services
by the noninstitutionalized elderly is lower than the prevalence of
mental illness or psychiatric disorder would warrant (Shapiro, 1986;
Hall, 1983; Taeuber, 1983~. The presence of unmet need for mental
health services among the elderly may also, or alternatively, sig-
nal "a lack of recognition or willingness to accept the presence of a
mental or emotional problem that should be brought to medical at-
tention and the infrequency of detection of an emotional problem by
the primary care clinicians (Shapiro, 1986~. Even when the elderly
seek care, health care professionals often prefer to spend time with
younger patients whose ailments are more likely to be curable than
with elderly patients needing chronic care (Kane et al., 1981; Office
'of Technology Assessment, 1985b). It should also be recognized that
Medicare coverage of mental health problems is much more ignited
than coverage under many general health insurance programs.
OCR for page 185
HEALTH SERVICES UTILIZATION
DATA SOURCES ON HEALTH CARE UTILIZATION
185
The remainder of this chapter reviews the adequacy of federal
data sources on the use of available health care services by the elderly,
both through the formal and the informal health care systems. The
discussion is organized around four major issues: the availability of
trained health personnel to work with the elderly; ejects of changes
in the organization, provision, and coverage of health care services;
the relationship between health status and health service utilization;
and equity in access to care.
Information on health services utilization by the elderly is gen-
erated by three types of federal data collection activities: provider-
based surveys, general population surveys, and administrative rec-
ords maintained by federal agencies. Provider-based surveys generate
information about health services utilization by surveying samples of
providers of care, such as hospitals, physicians, and nursing homes.
Population-based surveys obtain such information by interviewing or
making observations on samples of individuals selected from the gen-
eral population or certain segments of it. These two approaches to
data collection are complementary and, in fact, some surveys sample
both providers and populations that is, they have both provider
and population components as integral parts of the survey. Adminis-
trative records are tools developed by federal agencies mainly for the
purpose of managing and monitoring federal programs, e.g., records
maintained by the Health Care Financing Administration to manage
and monitor the Medicare program. These records are an important
source of data on the use of health services by the elderly.
Data Related to Health Personnel Trained to Work
With the lDIderly
The quality of care and the quality of life for the elderly with
multiple and complex medical problems are enhanced when medical
care is provided by health care professionals, and alDied personnel who
are trained and experienced in geriatrics and gerontology (Kane et al.,
19803. Both professionals, such as physicians and social workers, and
support personnel, including nurses' aides and home health workers
who provide hands-on and continuing care, play a large role in the
everyday life of older persons who are frail or ill.
Comprehensive data on the numbers of professionals and allied
health personnel who presently render direct care to the elderly do
not exist. Nor is there information on the numbers that will be
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186
AGING POPULATIONr IN THE TWENTY-FIRST CENTURY
needed in the future to meet the health needs of the rapidly grow-
ing elderly sector of the population. Some federal agencies, such as
the Bureau of Health Professions of the Health Resources and Ser-
vices Administration (U.S. Public Health Service), have attempted
to collect some data. In 1983 and 1984, the Bureau sampled licensed
practical nurses (LPNs) and registered nurses to determine how many
work in settings that render care to the elderly (persona] communi-
cation, Thomas Hatch, Chief, Bureau of Health Professions). Data
sets, privately generated for internal use by professional societies or
associations, generally do not identify members who work with or
provide services to the elderly. An exception is the American Medical
Association's survey of its member physicians, which collects data
on the numbers who report a primary interest in geriatrics (National
Institute on Aging, 1984b). Moreover, many private data sources
have typically not been developed as information bases for public
use.
The Health Research Extension Act of 1985 (U.S. Congress,
1985), Section 8, called for a Study of Personnel for Health Needs
of the Elderly. It directed the secretary of the U.S. Department
of Health and Human Services to "conduct a study on the ade-
quacy and availability of personnel to meet the current and pro-
jected health needs (including needs for home and community-based
care) of elderly Americans through the year 2020n (U.S. Congress,
1985~. Chapter 5 includes a brief description of the contents of the
secretary's report.
The study defines health personnel broadly to include not only
the usual professionals who deal with and render care to the elderly
in both institutional and noninstitutional settings (e.g., physicians,
registered nurses, social workers), but also nursing home and hospital
administrators, specialized geriatricians, all varieties of acute and
Tong-term care nurse and allied personnel below the bachelor's level
(such as I`PNs and aides), and health researchers, among others.
Other noteworthy activities include the voluntary efforts of those
professional associations and membership organizations that cur-
rently collect, or attempt to collect, information on the health and
related services their members provide to the elderly and the settings
in which they render such services. The pane! encourages these asso-
ciations and organizations to continue and refine their data collection
activities in this area ant] suggests that others join them in collecting
such information on their own members.
The pane! is concerned, however, about the lack of routine and
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HEALTH SERVICES UTILIZATION
187
standardized data collection efforts by the federal government needed
to determine the current and future estimated supply of professionals
and support personnel who are engaged in providing health care to
the elderly. The pane! encourages federal agencies to give further
attention to mechanisms by which such information can be generated.
Measuring the Effects of Changes In the Organization, Provision,
and Coverage of Health Care Services
Changes in Provider Characteristics
Changes in the organization and provision of health care and
related services, as discussed more fully in Chapter 5, are having
and will continue to have a considerable impact on the service uti-
lization patterns not only of the general population but also of the
elderly. Provision must be made to monitor their impact over time
through various continuing and periodic surveys, both provider- and
population-based.
Recommendation 9.1: The pane] recommends that federal
agencies give high priority to reviewing and modifying the
contents of administrative record systems, provider-based
surveys, and, to the extent feasible, population-based sur-
veys to reflect the rapidly changing patterns in health service
delivery. These modifications should enable respondents and
surveyors to distinguish among the various types of health
plans in use, including the varieties of capitated plans, and
to detect differences in their cost-sharing provisions. Stan-
dard definitions and formats for recording the health plan
information should be used by all agencies collecting such
data.
Physicians and Utilization of Their Services An important source
of utilization data is the National Ambulatory Care Survey, which
collects data on office visits made by ambulatory patients to non-
federal physicians engaged principally in office-based patient care
practice. The unit of analysis for this survey is the physician-patient
encounter (National Center for Health Statistics, 1984b).
At present, this survey has several limitations that affect its util-
ity as a major source of national data on the content and volume of
physician services received by the elderly and the general population.
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188
AGING POPULATION IN THE TWENTY-FIRST CENTURY
One is its periodicity. Instead of being an annual survey with con-
tinuous collection of data as initially planned and conducted, it was
changed to a triennial survey because of budget considerations in the
National Center for Health Statistics (Shapiro, 1984~. A second lim-
itation concerns its coverage. At present, the sampling frame for this
survey is offlce-based physicians in solo or group practice (including
HMOs). Excluded are physicians whose practice is hospital-based
and those who are federally employed. The latter results in a gap in
information about service utilization by veterans and dependents of
those in military service. The former exclusion means that physician
visits of minority populations residing in urban areas are underrepre-
sented because members of such populations are relatively high users
of hospital-based physician services, including emergency services.
The sampling frame also excludes physician practices in other care
settings such as the rapidly expanding surgi-centers, where many
procedures formerly performed on an inpatient basis are now taking
place. Until surgi-centers are included in NAMCS, it will remain un-
clear to what extent and for what procedures the elderly are receiving
care in these facilities.
A third limitation of this survey as a source of national utilization
data on the elderly is that the report form concerning physician
visits does not address specific health care needs of the elderly. The
inclusion of items, such as whether tests for preventable illnesses and
disabilities were performed during the visit, would enhance the utility
of this survey for physician-patient encounters that involve older
persons (see Chapter 5 for the panel's recommendation pertaining to
this aspect of the National Ambulatory Medical Care Survey).
Recommendation 9.2: The panel recommends that the Na-
tional Ambulatory Medical Care Survey sampling frame be
expanded to include physicians practicing in federal hos-
pitals, hospital outpatient clinics, surgi-centers, and other
alternative care centers.
Hospitals and Utilization of Their Services The National Hospital
Discharge Survey, a continuous survey conducted by the National
Center for Health Statistics since 1965, is the primary survey-based
source of information on inpatient utilization of short-stay nonfederal
hospitals. Its purpose is to produce statistics that are representative
of the experience of the U.S. civilian population discharged from
short-stay hospitals exclusive of military and Veterans Administra-
tion hospitals. It samples discharge record abstracts in a sample
OCR for page 191
NEALTN SERVICES UTILIZATION
191
Interview Survey (NHIS, see Chapter 3) and the National Ambula-
tory Medical Care Survey both collect some data about dental visits,
and the planneci National Medical Expenditure Survey (discussed
below) is expected to do so as well, none of them does so in depth.
The NHIS did include a supplement on edentulousness in 1971. The
National Nursing Home Survey (see Chapter 7), which is designee] to
be used with the elderly, likewise does not deal with this issue except
in a very cursory manner. The Medicare statistical system does not
collect such data, because ordinary dental care is not reimbursed
under Medicare.
The National Health and Nutrition Examination Survey (de-
scribed in Chapter 3) is an exception, as far as dental health data
are concerned. This survey measures and monitors the health and
nutritional status of the U.S. population through direct physical ex-
am~nations, physiological and biochemical measurements, and per-
sonal interviews administered to a sample of the noninstitutionaTized
population ages 6 months to 74 years. NHANES ~ (1971-1975) in-
cluded a dental examination for a part of the sample, and interview
items pertaining to perceived clental status and needs on its Health
Care Needs Questionnaire (National Center for Health Statistics,
1985c). NHANES IT (197~1980) did not include dental health in its
protocols. The Hispanic Health and Nutrition Examination Survey
(HHANES), administered from 1982 to 1984 to a sample of Hispanics,
included both a dental examination and interview items pertaining
not only to perception of dental health, but also to utilization of
dental services and barriers to dental care. NHANES ITI, to begin in
1988, is expected to extend the age of the elderly covered in the sam-
ple to 84 (see Chapter 3 for a recommendation concerning sampling
of the elderly for NHANES ITI) and to have a longitudinal compm
nent. It will also include a dental examination to determine trends in
the prevalence of dental caries and periodontal disease and interview
items on dental status very much like those included in NHANES
(personal communication, Kurt Maurer, National Center for Health
Statistics). The pane] concurs with the National Institute of Dental
Research's position regarding the desirability for better national data
on the oral health status and dental utilization behaviors of the el-
derly (U.S. Department of Health and Human Services, 1986b). The
need for more extensive inquiry is exceedingly important because
dental status and care when needed are central to the ability to di-
gest and gain nutritive value from food, and they affect the quality
of life experienced by the elderly.
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192
AGING POPULATIONIN THE TWENTY-FIRST CENTURY
Recommendation 9.3: The pane} recommends that the Na-
tional Center for Health Statistics develop a set of interview
items on dental care utilization of increased relevance to the
elderly to be included in the National Health and Nutri-
tion Examination Survey in order to provide more detailed
information on dental status and care.
:Rehabilitative Care and Serrices Rehabilitative care and services
are provided to persons impaired from acute or chronic disease to
help maintain existing residual function, unprove function, or restore
independent functioning. Such care and services are not intended to
cure disease (Office of Technology Assessment, 1985b). They may be
heavily technology-intensive or involve the use of very simple devices
or none at all. Typically such services are provided by physiatrists
(physicians specializing in rehabilitation), physical and occupational
therapists, nurses, and speech therapists. Most such services are
rendered in hospitals and nursing homes, but they are also provided
in the home and at community or senior centers Dolce of Technology
Assessment, 1985b). Federal data collection efforts are relatively
weak in the area of rehabilitative care and services provided to the
elderly. Both the National Nursing Home Survey and the Medicare
statistical system collect some data the former In the course of
sampling nursing home facilities and the services they provide to
individual, and the latter because Medicare reimburses for some
rehabilitative services. Because rehabilitative care and services are
so central to the well-being of the disabled and ill elderly even
very small improvements in functioning can make a difference in the
quality of life experienced by a nursing home resident the pane!
believes that utilization of such services by the elderly should be
documented.
Recommendation 9.4: The pane! recommends that increased
attention be given to the inclusion of questions concerning
rehabilitative care in both ongoing provider- and population-
based surveys and those that may be initiated in the future.
Rehabilitative care is provided in short- and long-term care fa-
cilities as well as on an outpatient basis. Facilities other than nursing
homes that provide rehabilitative care as their primary focus are not
currently included in the National Master Facility Inventory, which
serves as the sampling frame for the National Nursing Home Sur-
vey. In Chapter 7 the pane! recommended that the inventory be
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HEALTH SERVICES UTILIZATION
193
expanded to include many different kinds of facilities that provide
long-term care, including those that provide rehabilitative care, to
facilitate data collection on elderly residents. Adoption of that rec-
ommendation would increase the feasibility of collecting survey data
on the utilization of institution-based rehabilitative services by the
elderly. Such data would complement the Medicare data that are
also available on elderly users of Medicare-reimbursed rehabilitative
services.
Utilization of Mental Health Services The extent to which the gen-
eral population and the elderly use mental health services provided
by specialists or general practitioners is not well documented in
population- and provider-based surveys such as those conducted by
the National Center for Health Statistics. A notable exception is the
Epidemiological Catchment Area Program of the National Institute
of Mental Health, conducted by academically based investigators in
five local areas, in collaboration with the NIMH, as described in
Chapter 1. With respect to utilization of services, results show that
the elderly are more likely to have unmet need for mental health care
than younger persons (Shapiro et al., 1985~. They are also far more
likely to turn to providers of general medical services than mental
health specialists when they seek care for a mental or emotional
problem (Shapiro, 1984~.
Important as the ECA is, there remains a need for periodic
information on a national scale concerning the extent to which the
elderly and the population generally receive mental health services
and from which sectors of care.
Recommendation 9.5: The pane] recommends that the Na-
tional Center for Health Statistics explore with the National
Institute of Mental Health means by which the use of men-
tal health services by older adults, whether provided by
specialty or general health care practitioners, can be disag-
gregated from their use of other health services in national
surveys, both population- and provider-based.
Changes in Utilization Patterns
The dynamic nature of financing and delivery of health care
discussed in previous chapters may be expected to have both short-
term and long-term effects on patterns of utilization of a broad
spectrum of ambulatory and institutional care. The longitudinal and
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194
AGING POPULATION IN THE TWENTY-FIRST CENTURY
cross-sectional periodic surveys already considered are designed to
meet the need for this type of information.
It should be noted that while the National Medical Expenditure
Survey described in Chapter 8 is directed pr~rnarily at econorn~c is-
sues, it is designed to provide extensive health services utilization
data on many components and sources of care relevant to the elderly.
Current plans focus on information for two age groups, 65-74 and
75 and over. However, since the age group 85 and over is the most
rapidly growing segment of the population and the group that makes
the greatest use of health care services, it wait be critically important
in future surveys to collect information on the use of health care
services by this age group. Therefore, the pane! reiterates its recom-
mendation for augmentation of the sample of the aged population in
future national medical expenditure surveys (Recommendation 8.2~.
A potentially useful approach for obtaining a larger sample of the
oldest~old in the NMES would be to integrate the sample designs
for the NMES and the NHIS. The pane] recognizes that the design
and cost issues for such an approach are being carefully explored
(National Center for Health Statistics, 1987a).
The pane} design of the current National Medical Expenditure
Survey will permit analysis of changes in utilization and expenditure
patterns over the course of a year. However, to capture trends in
utilization patterns in response to changes in delivery and payment
systems over time, it wiD be necessary to repeat the survey every
few years. Therefore, the pane} reiterates its recornrnendation for
a periodic national medical expenditure survey (Recommendation
8.3~.
Relationship Between Health Status and Health Services Utilization
It is important to be able to relate the health and personal
status characteristics of the elderly to their utilization of health
services. Information on trends in the health status of the population
could then be used to forecast changes in health services utilization
patterns. The Medicare administrative records, or Medicare files,
which contain utilization data on the elderly population age 65 and
over who use the Medicare benefits to which they are entitled, are
a useful source of data. Although there are an estimated 28 million
Medicare beneficiaries in all (Young, 1985), only 75 percent of the
elderly actually have Medicare claims on their behalf in any one
year. The files are particularly useful in the area of hospitalization
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HEALTH SERVICES UTILIZATION
195
for acute episodes and other health services reimbursed by Medicare,
but linkage to sources of information on total health services is
needed.
The data files established to manage and monitor the Medicare
program can be linked with records of the elderly in national surveys
via items the two data bases have in common. Prominent among
these surveys are the National Health Interview Survey, the planned
National Medical Expenditure Survey, the National Nursing Home
Survey (which includes a population component), and the Survey
on Income and Program Participation. Performing such linkages
would afford the opportunity to analyze health services utilization
patterns of the elderly, derived from their Medicare files, in relation
to their personal and health status characteristics, attitudes, and
other pertinent socioeconomic and demographic information derived
from interview surveys. Furthermore, such linked data sets would
provide a rich source of longitudinal information on health services
utilization by the elderly. This would make it possible to relate health
status and other characteristics of the elderly to subsequent use of
health services, and thereby to improve the capability of projecting
future demands and costs for health services.
The type of linkage discussed is technically feasible and can be
achieved without incurring the additional cost of collecting new data,
although not without administrative costs. Although the Medicare
files were established primarily to assist with administration and
monitoring the Medicare program, the development of the Medicare
Automated Data Retrieval System, as discussed in Chapter 8, will
facilitate access to the Medicare files for research purposes (Lichen-
stein et al., no date). For a fuller discussion of the concept of data
linkages and the methodology to achieve them, see Chapter 10; is-
sues of confidentiality and access to records are also discussed in that
chapter.
Recommendation 9.6: The pane! recommends that (a) link-
age with Medicare records be performed on a routine basis
for persons age 65 and over who are respondents to popu-
lation surveys that collect health data and (b) the Health
Care Financing Administration and the National Center for
Health Statistics explore linking the continuous National
Health Interview Survey with the Medicare Automated Data
Retrieval System, when the latter becomes operational.
1
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196
AGING POPULATION IN THE TWENTY-FIRST CENTURY
Access to Care
In the two decades since the enactment of Medicare and Medi-
caid, impressive strides have been made in ensuring that more older
Americans have access to the health care system. In additions a
backlog of long-neglected needs, especially among the elderly and the
poor, was specifically addressed. For example, cataract operations
that enable the elderly to improve their vision increased significantly
following the introduction of Medicare. In 1982, the rate for this
operation for both elderly men and women was three times that in
1965 (Rice, 19863.
Medicaid also has been successful in improving access to physi-
cian services for the population it covers the poor and the "medi-
cally needy." Evidence suggests, however, that those near-poor not
covered by Medicaid continue to lag well behind others in the use of
services (Davis, 1985~. Access to care still varies among subgroups of
the population by income, race, and place of residence (President's
Commission, 1983~. Since the poor tend to be sicker than others,
the higher medical care use rates among the poor do not necessarily
indicate that they get more care given similar health status. An indi-
cator of this is that poor persons of all ages, including the elderly, who
report their health as fair or poor have significantly fewer physician
visits than their counterparts in higher income groups (Kleinman et
al., 1981~. A major issue concerns the effect of changes in the de-
ductible and coinsurance provisions of Medicare and in the eligibility
and benefits under Medicaid on services utilized by the economically
disadvantaged.
The growth of for-profit health care, the adoption of business-
oriented approaches by health care providers, and the growth of
competition in the medical care market may contribute to an unin-
tended increase in the barriers to access to health care for our need-
iest citizens- many of whom are old. Changes in systems of care
(HMOs, PPOs, etc.), increased emphasis on noninstitutional sources
of care, and regulatory measures to contain costs (e.g., diagnosis-
related groups for hospital reimbursement) are relevant for all seg-
ments of the aged and raise questions about many aspects of access,
including what we mean by access and whether significant changes
are occurring.
In a broad sense, access may be defined as the achievement of an
appropriate match between need and utilization of services responsive
to need. From this perspective, equity of access, then, may be said
to exist "when services are distributed on the basis of need rather
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HEALTH SERVICES UTILIZATION
197
than as a result of structural or individual factors such as a fa~niTy's
income level, person's racial characteristics, or the distribution of
physicians in an area" (Office of Technology Assessment, 1985a:963.
This leads to a close examination of factors that influence pat-
terns of utilization of services among the elderly and changes that
occur as a result of public and private initiatives in the health field.
A useful framework for considering correlates of health care is to
classify them as predisposing (e.g., social, demographic, psycholog-
ical, and attitudinal characteristics of users and potential users of
services), enabling (e.g., financiaIresources, availability of services,
barriers to care), and need (objective or perceived need for care (see
Andersen et al., 1983, for a brief review).
By now, these concepts are well established and a number of
national population-based surveys have included items to measure
access to care. Among these are the National Health Interview
Survey (and its 1974 supplement on medical care availability and
barriers to care), the Hispanic HANES (administered between 1982
and 1984), the Long-term Care Survey, the Longitudinal Study on
Aging, the Survey of Income and Program Participation, and the
National Medical Expenditure Survey and its predecessors. One
national survey was designed explicitly for the purpose of measuring
access to care among the general population the National Survey
of Access to Medical Care of the Center for Health Administration
Studies of the University of Chicago, first conducted in 1970 and
subsequently conducted in 1976 and in 1982 (see National Research
Council, 1986 for a description).
The kinds of questions designed to measure access to care on the
federal surveys include items concerning whether the respondent has
a regular source of care and where he or she would go for care in case
of need, the regularity or frequency of service utilization, the most
recent visit or consultation with a health practitioner, queuing or
waiting time to see health care providers, transportation time, and
coverage or reimbursement for health care services. The Long-term
Care Survey asks impaired elderly people directly about unmet needs
for health care within the past month and why medical assistance
has not been sought in the presence of unmet need. Perhaps the
most comprehensive set of access questions to appear on a federal
survey is found in the National Medical Expenditure Survey. This
survey asks in detail about the usual source of care when ill, the
use of a particular physician and dental office or clinic, the mode of
transportation and length of time it takes to reach providers, waiting
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198
AGING POPULATION IN THE TWENTY-FIRST CENTURY
or queuing time to be seen, and insurance coverage and out-of-pocket
costs for medical and health care.
Population-based surveys will continue to have a central role in
identifying the impact of health care policies on access to services.
This is particularly true for the continuous National Health Inter-
view Survey, the periodic expenditure survey, the latest version of
which is the National Medical Expenditure Survey, and the Lon-
gitudinal Study on Aging. Further, such population-based surveys
can determine access problems of potentially vulnerable or high-risk
segments of the population, such as the poor, the uninsured, specific
racial and ethnic minorities, and the oldest-old. Surveys that include
health status measures as well as access indicators make it possible
to link adverse outcomes, such as the presence of health events that
may reflect inadequate care or unmet need, with demographic and
socioeconomic characteristics of individuals.
The National Health and Nutrition Examination Survey has
the potential to be a particularly important vehicle for obtaining
information on access to care in relation to health status. This is
so because that survey, as its predecessors did, will collect objective
indicators of health status derived from physical examinations and
physiological and biochemical measurements along with information
on health services received, which serve to determine unmet need
whether it is recognized or unrecognized.
The elderly or segments of the elderly population may experi-
ence special or different problems or barriers in securing access to care
than the remainder of the population. Not enough is currently known
about the factors that affect utilization of health services by the el-
derly and about the access barriers experienced or perceived by older
persons (Shapiro, 1986~. Psychological factors or attitudes common
among the present cohort of elderly, or particular subgroups of it,
may play a role. The under-consumption of mental health services
by the elderly relative to the prevalence of mental health problems
among this population has been cited earlier in this chapter. In ad-
dition, demographic factors, educational level, and functional status,
either mental or physical, may also affect the access characteristics
of the elderly in special ways.
It is clear that while a great deal is known about access, there
is need for a sharper focus on the status of access to care among
different subgroups of the elderly and the effects on access of public
policies in the health field.
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HEALTH SERVICES UTILIZATION
Recommendation 9.7: The panel recommends that the Na-
tional Center for Health Statistics, the National Center for
Health Services Research and Health Care Technology, the
National Institute on Aging, the National Institute of Mental
Health, and other federal agencies that conduct or sponsor
population-based surveys concerning the health of the el-
derly review the access-related items on existing and planned
national surveys, whether privately or publicly sponsored,
and work toward developing a standard set of access items
that would be appropriate for use with elderly respondents
in federally sponsored population surveys.
199
Population Subgroups
The Veteran Population The growing proportion of the elderly,
particularly among men, who are veterans has been commented on
extensively. The Veterans Administration is in a position to develop
health-related information for the subgroup of veterans that utilize
VA services. However, for a more complete understanding of patterns
of care, health status, and access problems among veterans, it is
necessary to turn to general population surveys.
The VA has conducted special surveys of veterans. Most of the
surveys and data systems reviewed in this report identify whether or
not the respondent or sampled person is a veteran, and these surveys
have the advantage of providing trend data.
Recommendation 9.8: The pane! recommends that the Vet-
erans Adrn~nistration take advantage of the information
about veterans included in surveys and administrative rec-
ords of other agencies to develop a data base for policy use.
The Poor and Near-poor Elderly The Medicaid program is the
principal source of assistance to the poor and near-poor who seek
health services and are not otherwise covered or eligible to receive
such services. Although Medicaid is administered at the state level,
national estimates of health services utilization by the Medicaid-
eligible elderly who enroll in the program are available through the
Medicaid Eligibility Quality Control system (MEQC). The purpose of
the MEQC is to detect errors in eligibility determination and claims
payments and misutilization by third-party payers. A sample of
approximately 400,000 Medicaid enrollees in all states and territories
(except Arizona, which did not participate in the Medicaid program
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200
AGING POPULATION IN THE TWENTY-FIRST CENTURY
at the time the sample was selected) is available for analysis of
enrollee characteristics by service utilization characteristics. This
data base shows promise of being developed into a useful data base
of information on the poor and near-poor elderly (AdIer, 1982~.
The Medicaid Tape-to-Tape project, described in Chapter 8 also
developed a data base, which, although Innited to five states, pro-
vides utilization data on the poor, including the poor elderly who
are enrobed in the Medicaid program in those states. For the panel's
recommendation to the Health Care Financing Administration con-
cerning elderly users of Medicaid services, see Recommendation 8.13
in Chapter 8.
The Rural Population A recent study of the National Research
Council (1984) identified residents of rural areas as an underserved
population and therefore likely to underutilize health care services
relative to the utilization rates of other sectors of the population. The
limited availability of health care providers, facilities, and services
for health care in rural areas no doubt contributes to the under-
utilization of health care services by rural residents, including the
rural elderly, according to that report. Information on the elderly's
use of Medicare-covered services can be obtained from the Medicare
Statistical System. Better data are needed, however, on compre-
hensive health services utilization and access to care on the part of
the rural population generally and of the rural elderly in particular
nationwide.
Recommendation 9.9: The panel recommends that the Na-
tional Center for Health Statistics and the National Center
for Health Services Research and Health Care Technology
take action to strengthen information regarding health ser-
vices utilization and access to care among the rural pop-
ulation, by designing population-based surveys to include
sufficiently large samples of the rural elderly population to
provide suitably precise estimates for analytic evaluation of
this population.
While the pane] has concentrated on national data programs, it
is important to recognize that two special studies, the Established
Populations for Epidemiological Studies of the Elderly sponsored by
the National Institute on Aging and the Epidemiologic Catchment
Area, the research program conducted cooperatively by the National
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201
IDsthute of Sleuth He~tb and academlcaDy bred 1uvestlgators, lu-
~ude paneh ~ rural elderly people ~ selected states and lades
0~a and North CaroUn~ far the EPESE, and St. Hula Sours
and Durban North Corolla, far the ECAj. Ibese two Judas oF
tar unlace opportunlt~s to document the bet services utOlz~tlon
patterns of the rural elderk ~ these locatlons. Abe panel urges tab
these rural elderly panes be Ballad on ~ lon~tudloal bails.
Representative terms from entire chapter:
health statistics
