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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

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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

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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.

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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

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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.