Geographic Variation in
Medicare Utilization:
Is Social Capital a Factor?
Jackson Williams
AARP Public Policy Institute
Note: The views expressed herein are for information, debate, and
discussion and do not represent those of AARP .
Number of Hospital Days
Last Two Years of Life
Under 18 days
18 to 19 days
19 to 20 days
Over 20 days
Source: Dartmouth Atlas of Health Care (Chronically Ill Medicare Enrollees 1999-2003).
Number of Doctor Visits
Last Two Years of Life
Under 45 visits
45 to 49 visits
50 to 54 visits
Over 55 visits
Source: Dartmouth Atlas of Health Care (Chronically Ill Medicare Enrollees 1999-2003).
Prescribing of Brand Versus
Generic Drugs
No data available
Under 500
500 to 540
540 to 580
Over 580
Source: Express Scripts 2005 Generic Drug Usage Report.
Hospital Patient Safety Incidents
Under 800
800 to 900
900 to 1,000
Over 1,000
Source: AARP PPI Analysis of Medicare Claims Data, 2000-2003.
Social Trust
General Social Survey
No data available
Under 350
350 to 400
400 to 450
Over 450
Social Capital Theory
• Origins in Political Science – Popularized
by Robert Putnam
• Effects of Culture on Social Behavior
• First Applications Were to Corruption
• Applied to Health/Mortality by Kawachi
• Applied to Health Care Quality by Skinner
• My Research – Applying to Medical Errors
and Intensity of Utilization
Social Capital Theory:
Four Dimensions
• Vertical Relationships – Corruption
• Self-Motivation – Achievement
• Horizontal Relationships (Community) –
Accidents/Claiming
• Horizontal Relationships (Individuals) –
Consumer and Other Transactions
Methodology of Paper
• Ecological, Cross-Sectional Regression Analysis
of Utilization Intensity: Dartmouth’s Medicare
Statistics; Imaging Growth, Drug Prescribing,
Caesarean Deliveries
• GSS “Can people be trusted?” Query
• Controls for Beds, Specialists, Proxies for
Patient Preference (Insurance Take-Up),
Practice Style (Regional VA Patterns)
• Apply Coefficients to Dartmouth Findings
Social Capital Theory
Applied to Hospital Days, L2YOL
• National Average: 19.6 days
• Minnesota Average: 17.1 days
• Control Variables: Practice Style (as seen
in VA system); Hospital Beds; Patient
Preference (as seen in employee
insurance take-up)
Social Capital Theory
Applied to Hospital Days, L2YOL
• National Average: 19.6 days
• Minnesota Average: 17.1 days
• Practice Style reduces by 0.7 day
• Fewer Hospital Beds reduces by 0.25 day
• Social Trust reduces by 2 days
• Patient Preference not significant in this
model
Social Capital Theory
Applied to Utilization
• Information Asymmetry Between Doctor
and Patient Allows Opportunistic Behavior
• In Places Where Social Capital is Low, Is
Doctor More Likely to Induce Demand?
• Geographic Pattern is Similar to Predatory
Lending, Deadbeat Dads
• Policymakers Must Consider: Is There a
“Pattern of Pathology” in Health Care?