Higher Utilization, Lower Death Rate For Florida's Medicare Enrollees
Raises Questions About Equity, Quality, Patients' Preferences

Health Affairs Articles Ask If Doctors' Practice Patterns Drive Up Spending
And If Elderly Floridians Live Healthier Lifestyles

BETHESDA, MD — Elderly Floridians use more health care and have a lower death rate than seniors in other states, but higher utilization is probably not responsible for lower mortality rates, according to a new Web-exclusive article published on the Health Affairs Web site.

In an essay titled "Floridian Exceptionalism," Stanford University health care scholar Victor Fuchs examines Florida seniors' mortality rates and health care utilization, and raises several possibilities for the lower death rate besides elderly Floridians' famously high health care use.

After such variations as demographics are taken into account, Medicare spends 25 percent more for beneficiaries in Florida than it does for beneficiaries in other states, and those Floridians have a 10 percent lower mortality rate.

"Could greater utilization explain lower mortality?" Fuchs says. "I doubt it, because it has always been difficult to show that differences in availability or use of medical care across areas of the country has much if any favorable effect on mortality."

Among the other explanations for that lower mortality rate, Fuchs says, are climate, in-migration of healthy beneficiaries, out-migration of sicker beneficiaries, and social support in age-segregated communities.

The higher utilization, meanwhile, can be explained by differences in preferences between the Florida seniors and seniors in the other states, or by physician-induced demand. Under the first theory, Fuchs says, "migrants come to Florida in part because they are very health-conscious and predisposed to use more medical care.

"Another possibility is that their preferences for care are altered once they are in Florida, as a result of their interactions with their peers in age-segregated communities," he says. "Patients' views and expectations about what constitutes appropriate care for any given symptom or diagnosis are shaped in large part by what friends and neighbors received in similar circumstances."

Whether physicians induce demand, however, is less clear, Fuchs says. Florida has a bigger supply of physicians, who can drive demand through referrals. Fuchs points to a study demonstrating that when compared to the rest of the country, elderly Floridians use relatively less physician office visit services and relatively more diagnostic and treatment outpatient services, which are more susceptible to physician inducement.

But there's a problem with that theory, he says. "If there is an abnormally large supply of physicians in Florida, that could be a response to an abnormally large demand for medical care by Floridians," Fuchs says. "The explanation that a large supply induces a large demand requires a demonstration that the large supply appears in Florida independently—that is, not in response to demand. This independent appearance of a large supply of physicians in Florida has not been demonstrated."

Fuchs says that policy analysts should not yet draw any conclusions about Florida's exceptional position in health care spending and use patterns, as well as death rates. While some argue that higher spending on Florida's Medicare beneficiaries is unfair to beneficiaries elsewhere, few say how it should be curbed, Fuchs says. Meanwhile, learning more about Florida seniors' lower mortality rates could benefit all Medicare beneficiaries.

Four Perspectives accompany the Fuchs article. John Bertko, Humana vice-president and chief actuary, says that new risk-adjustment data from the Centers for Medicare and Medicaid Services shed some light on how Florida seniors compare to seniors in the rest of the country, but he adds that the data also raise questions about physicians' role in higher health care use. Health care consultant Lynn Etheredge argues that the variations in health care spending and mortality show that Medicare isn't getting the most value for its purchasing dollar, and the solution is greater use of evidence-based medicine and best practices nationwide.

Jill Quadagno, with the Florida State University Pepper Institute on Aging, suggests that the strong social support in age-segregated communities, along with the health care and social support that result from having a large number of assisted-living facilities, explains the lower mortality, and she argues that this could be a lesson for the rest of the country. Finally, Jonathan Skinner and John Wennberg argue that physicians are the primary drivers of higher health care spending for Medicare beneficiaries; they point to data showing that health care use by chronically ill beneficiaries in the last six months of life is above the national average in four Florida regions.

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research.

©2003 Project HOPE–The People-to-People Health Foundation, Inc.