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?