Dissertation Title："Medicare Beneficiaries and Market Variations in Service Use, Quality of Care, and Plan Choice"Paper 1 examined relationships between an area’s intensity of service use and patient experiences, complementing research that showed markets with more intensive use of health care services did not have better technical quality of care or clinical outcomes. This analysis examined associations between a hospital referral region’s intensity of service use in Medicare fee-for-service and managed care with 8 measures of patient experiences with care from the 2003 Consumer Assessments of Healthcare Providers and Systems® surveys for Medicare beneficiaries 65 years or older. Except for fee-for-service beneficiaries’ overall ratings of their personal physicians, Medicare beneficiaries in markets characterized by intensive service use did not report better experiences with care. This negative trend was strongest for managed care beneficiaries. To realize potential benefits of coverage choices, Medicare beneficiaries must be aware of Medicare managed care.

Paper 2 assessed relationships among beneficiary awareness of the managed care program and the number of Medicare risk plans, managed care penetration, and stability of plans in an area. Using 2002 Medicare Current Beneficiary Survey data, we analyzed 9,277,952 Medicare fee-for-service beneficiaries never enrolled in Medicare managed care but had at least one plan available in their area. Having more Medicare risk plans available was significantly associated with greater awareness, and having an intermediate number of plans (2-4) was associated with more accurate knowledge of Medicare risk plan availability. Clinical quality of care for Medicare fee-for-service beneficiaries is not better in markets where Medicare beneficiaries receive more intense treatment.

To learn if a similar relationship exists in Medicare managed care, Paper 3 examined associations between intensity of service use across hospital referral regions and 11 clinical quality of care measures from the 2003 Medicare managed care Health Care Effectiveness Data and Information Set. Similar to fee-for-service, Medicare managed care beneficiaries in high-intensity markets had a lower likelihood of receiving beta blockers after heart attack, breast cancer screenings, colorectal cancer screenings, and appropriate treatments for depression or osteoporosis after a hip fracture than their counterparts in low-intensity markets. An exception was managed care beneficiaries with hypertension in high-intensity markets were more likely to control their blood pressure than those in low- intensity markets.