Claims-based measurement shows many Medicare patients do not receive necessary care

November 06, 2000

Underuse of necessary care more likely among African Americans and those living in poverty areas

CHICAGO -- A measurement system using information from inpatient and outpatient claims of Medicare beneficiaries detects substantial underuse of necessary care, which is likely to result in negative outcomes for many elderly patients, according to an article in the November 8 issue of The Journal of the American Medical Association.

Steven M. Asch, M.D., M.P.H., of RAND, Santa Monica, Calif., and colleagues developed a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using data from Medicare part A and B claims.

According to the authors, efforts to measure needed care have traditionally focused on vulnerable populations, such as poor and uninsured patients, who have a higher risk of being sick, and whose access to care is below average. According to background information cited in the study, numerous studies have shown that these vulnerable groups underuse needed services, have a lower likelihood of seeing a physician, higher use of emergency services, lower use of preventive care services, greater likelihood of delaying care, poorer health outcomes, and higher mortality rates. The recent push for cost containment in health care -- including managed care, fee restraints, and utilization review - has introduced the possibility that even fairly mainstream insured populations may encounter barriers to use of needed services.

For their study, the authors defined necessary care as care for which the benefits outweigh the risks, the benefits to patients are likely and substantial, and physicians have judged that not recommending the care would be improper. They developed indicators reflecting standards of acceptable care and those representing potentially avoidable outcomes. They assembled a 7-member expert panel of physicians to evaluate underuse indicators that were likely to be associated with poor outcomes for 15 common acute and chronic medical and surgical conditions.

The indicators span several phases of care, including prevention, initial evaluation, diagnostic tests, therapeutic interventions, follow-up, and monitoring for acute, chronic, medical, and surgical conditions. An automated system was developed to calculate the indicators, using Medicare administrative data.

The authors analyzed data from 345,253 randomly selected elderly U.S. Medicare beneficiaries in 1994-1996. "When we applied the system to Medicare claims data, our results suggested that underuse of necessary care is widespread for the 15 target conditions, even in the relatively well-insured Medicare population," they write. "For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time," they continue.

Underuse was more likely to occur among African Americans, residents of poverty areas, and those who lived in areas with a shortage of health care professionals. "Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none," the authors write.

The authors believe a claims-based system can be used in a variety of ways to inexpensively measure underuse. "Screening administrative data to determine areas of a health care system in need of further investigation is the first step in a continuous quality improvement framework, allowing identification of individual facilities or medical groups at risk," they write. "This system may be used to guide internal quality improvement efforts for large medical groups or plans, as well as purchasers' or regulators' evaluations," they continue.

"Future research, using chart reviews and patient surveys, is needed to directly validate the indicator system. However, the results of our initial application indicate substantial underuse, particularly among traditionally vulnerable populations," they conclude.
(JAMA. 2000; 284:2325-2333)

Editor's Note: This study was supported by a grant from the Physician Payment Review Commission (now Medicare Payment Advisory Commission). Dr. Asch's involvement was supported by a Career Development Award from the Veterans Affairs Health Services Research and Development Service. Co-author Christopher Hogan, Ph.D., was employed by the Physician Payment Review Commission at the time the research was performed.

Media Advisory: To contact Steven M. Asch, M.D., M.P.H., call Amanda Gaylor at 310/451-6913.

This release is reproduced verbatim and with permission from the American Medical Association as a service to reporters interested in health and behavioral change. For more information about The Journal of the American Medical Association or to obtain a copy of the study, please contact the American Medical Association's Science News Department at (312) 464-5374.

If you would like a comment from Jessie C. Gruman, PhD, executive director of the Center for the Advancement of Health, on this study, please call (202) 287-2829 or send email to

Posted by the Center for the Advancement of Health . For more research news and information, go to our special section devoted to health and behavior in the "Peer-Reviewed Journals" area of Eurekalert!, For information about the Center, call Petrina Chong, (202) 387-2829.

Center for Advancing Health

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