Health Care Utilization

Measures of health care utilization complement patient reports of barriers to care and permit a fuller understanding of access to care. Barriers to care that are associated with differences in health care utilization may have a more significant impact on health care quality than other factors. Landmark reports on disparities have relied on measures of health care utilization,^1,20 and these data demonstrate some of the largest differences in care among diverse groups. More recent efforts to inform health care delivery continue to include measures of health care utilization.²¹

Interpreting health care utilization data is more complex than analyzing data on patient perceptions of access to care. Along with access to care, health care utilization is strongly affected by health care need and patient preferences and values. In addition, greater use of services does not necessarily indicate better care. In fact, high use of some inpatient services may reflect impaired access to outpatient services.

Tables 3.1a and 3.1b summarize facilitators and barriers to care for various racial, ethnic, and socioeconomic groups. Tables 3.2a and 3.2b summarize findings on all core measures related to health care utilization. Because of the many factors that affect health care utilization, the key to symbols used in Tables 3.2a and 3.2b is different from that used for Tables 3.1a and 3.1b. Rather than indicating better or worse access compared with the comparison group, symbols on the utilization tables simply identify the amount of care received by racial or ethnic minority and socioeconomic groups relative to their comparison groups.

In 2006, the Nation's 14 million health services workers²² provided care at about 960 million office visits²³ and 673 million hospital outpatient visits²⁴ and treated 37 million hospitalized patients²⁴ and 1.4 million nursing home residents.²⁵ Each year, about 70% of the civilian noninstitutionalized population visits a medical provider's office or outpatient department, about 60% receives a prescription medication, and about 40% visits a dental provider.²⁶

National health expenditures totaled more than $2 trillion in fiscal year 2006, nearly double those of a decade earlier.²⁷ Health expenditures among the civilian noninstitutionalized population in America are extremely concentrated, with 5% of the population accounting for 55% of outlays.²⁸ In addition, a study using earlier data estimated that as much as $420 billion a year—almost one-fourth of all health care expenditures—are the result of low-quality care, including overuse, misuse, and waste.²⁹

Previous NHDRs reported that different racial, ethnic, and socioeconomic groups had different patterns of health care utilization. Asians and Hispanics tended to have lower use of most health care services, including routine care, emergency department visits, avoidable admissions, and mental health care. Blacks tended to have lower use of routine care, outpatient mental health care, and outpatient HIV care. Blacks had higher use of emergency departments and hospitals, including higher rates of avoidable admissions, inpatient mental health care, and inpatient HIV care. Individuals with lower SES tended to have lower use of routine care and outpatient mental health care and higher use of emergency departments, hospitals, and home heath care.

Dental Visits

Regular dental visits promote prevention, early diagnosis, and optimal treatment of oral diseases and conditions. Failure to visit the dentist can result in delayed diagnosis, overall compromised health, and, occasionally, even death.¹⁴

Figure 3.11. People who had a dental visit in the calendar year, by race, ethnicity, income, and insurance status, 2002-2006

         

                   

Key: AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.

Denominator: Analyses by race, ethnicity, and income performed for civilian noninstitutionalized population, all ages.

• There were no statistically significant changes in the percentage of people with a dental visit in the calendar year from 2002 to 2006 across racial, ethnic, or income categories (Figure 3.11).
• From 2002 to 2006, the gap between Blacks and Whites in the percentage of people with a dental visit in the calendar year remained the same. In 2006, the percentage was significantly lower for Blacks than for Whites (30.6% compared with 45.6%). The gap between NHOPIs and Whites was not statistically significant.
• During the same period, the gap between Hispanics and non-Hispanic Whites remained the same. In 2006, the percentage was significantly lower for Hispanics than for non-Hispanic Whites (26.5% compared with 49.7%).
• In 2006, the gap between poor people and high-income people remained the same. The percentage was significantly lower for poor (26.1%), near-poor (28.8%), and middle-income people (40.8%) than for high-income people (57.4%).
• Only NHOPIs and high-income people met the Healthy People 2010 target of 56% of people with a dental visit in the past year.
• From 2002 to 2006, the gap between people with public insurance and people with private insurance decreased. However, people with public insurance were still less likely than people with private insurance to have had a dental visit in the calendar year (32.1% compared with 50.9%).
• During this period, the gap between uninsured people and people with private insurance remained the same. People who were uninsured were about two-thirds less likely than people with private insurance to have had a dental visit in the calendar year (16.1% compared with 50.9%).

To distinguish the effects of race, ethnicity, and SES on health care utilization and to identify populations at greatest risk for barriers to health care utilization, this measure is stratified by income.

Figure 3.12. People who had a dental visit in the calendar year, by race and ethnicity, stratified by income, 2006

         

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.

Denominator: Civilian noninstitutionalized population, all ages.

Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.

• SES explains some, but not all, of the racial and ethnic differences in rates of dental visits (Figure 3.12).
• In all income categories except for poor, Blacks were significantly less likely than Whites to have had a dental visit in the calendar year (near poor, 23.5% for Blacks versus 30.1% for Whites; middle income, 32.0% for Blacks versus 42.9% for Whites; and high income, 44.1% for Blacks versus 59.2% for Whites).
• Hispanics at every income level were significantly less likely than non-Hispanic Whites to have had a dental visit (poor, 21.6% of Hispanics versus 28.9% of non-Hispanic Whites; near poor, 23.1% of Hispanics versus 33.6% of non-Hispanic Whites; middle income, 24.6% of Hispanics versus 46.8% of non-Hispanic Whites; and high income, 42.6% of Hispanics versus 60.5% of non-Hispanic Whites).

Emergency Department Visits

Without good access to health care, people sometimes resort to using the emergency department (ED) when care is needed. A high rate of ED visits may suggest that a population lacks access to preventive and routine care and other avenues of treatment. Delaying care until the need is urgent often results in poorer health outcomes and increased health care costs. It should be noted that high rates of ED visits, however, may also be the result of varying levels of patient need or preferences.

Figure 3.13. People who had a hospital emergency room visit in the calendar year, by race and income, ethnicity and income, insurance and income, insurance and race, and insurance and ethnicity, 2006

         

         

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.

Denominator: Civilian noninstitutionalized population, all ages.

Note: Estimates are based on self-report of emergency room visits. Data did not meet criteria for statistical reliability for Native Hawaiians and Other Pacific Islanders, poor Asians, Asians with public insurance or no insurance, or American Indians and Alaska Natives.

• From 1997-1998 to 2005-2006, the percentage of ED visits remained the same except for Blacks (data not shown).
• In 2006, Blacks were more likely to report that they had a hospital emergency room visit than Whites (16.4% compared with 13.3%; data not shown). Poor Blacks were also more likely than poor Whites to report that they had a hospital emergency room visit (22.7% compared with 19.1%; Figure 3.13).
• Asians were less likely to report that they had a hospital emergency room visit than Whites (5.5% compared with 13.3%; data not shown). Asians at every income level except poor were also less likely than their White counterparts to report that they had a hospital emergency room visit (near poor, 8.1% compared with 16.4%; middle income, 3.9% compared with 12.3%; high income, 5.6% compared with 11.2%).
• Hispanics were less likely to report that they had a hospital emergency room visit than Whites (12% compared with 13.6%; data not shown). Poor and near-poor Hispanics were also less likely than their White counterparts to report that they had a hospital emergency room visit (poor, 14.2% compared with 21.9%; near-poor, 11.5% compared with 18.8%).
• Poor people were almost twice as likely as people with high income to report that they had a hospital emergency room visit (19.6% compared with 11%). Near-poor people were also more likely to report that they had a hospital emergency room visit than high-income people (16.4% compared with 11%).
• People with public insurance were almost twice as likely as people with private insurance to report that they had a hospital emergency room visit (19.1% compared with 11.1%).
• Among people with private insurance, Asians were less likely than Whites to report that they had a hospital emergency room visit (5.7% compared with 11.1%).
• Among people with public insurance, Blacks were more likely than Whites to report that they had a hospital emergency room visit (21.8% compared with 18.4%) and Hispanics were less likely than non-Hispanic Whites to report a hospital emergency room visit (14.3% compared with 21.5%).
• Among people with no insurance, Hispanics were less likely than non-Hispanic Whites to report that they had a hospital emergency room visit (6.9% compared with 14.6%).

Potentially Avoidable Admissions

Potentially avoidable admissions are hospitalizations that might have been averted by good outpatient care. They relate to conditions for which good outpatient care can prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. Although all admissions for these conditions cannot be avoided, rates in populations tend to vary with access to primary care.³⁰ For example, better access to care should reduce the percentage of appendicitis admissions in which rupture has occurred.

Figure 3.14. Perforated appendixes per 1,000 admissions with appendicitis, by race/ethnicity, area income (median income of ZIP Code of residence), and insurance status, 2001-2006

         

Key: API = Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2001-2006.

Denominator: Patients hospitalized with appendicitis, age 18 and over.

Note: White, Black, and API are non-Hispanic groups. Quartile income categories are used instead of the NHDR's usual descriptive categories because that is how data are collected for this measure. Quartile 1 corresponds to the lowest income quartile, and Quartile 4 corresponds to the highest income quartile. Income categories are based on the median household income of the ZIP Code of the patient's residence. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population. Data for American Indians and Alaska Natives from the National Patient Information Reporting System can be found in Chapter 4 but are not collected by this data source.

• From 2001 to 2006, the gap between Blacks and Whites in the rate of hospital admissions for perforated appendix did not change significantly (Figure 3.14). In 2006, Blacks had a higher rate than Whites (323.4 per 1,000 compared with 278.7 per 1,000).
• In 2006, APIs and Whites were not significantly different in the rate of hospital admissions for perforated appendix.
• In 2006, there was no statistically significant difference between Hispanics and Whites (283.7 per 1,000 compared with 278.7 per 1,000).
• From 2001 to 2006, the gap between people living in poor communities (Quartile 1) and those living in high-income communities (Quartile 4) in the rate of hospital admissions for perforated appendix increased. In 2006, people living in poor communities (Quartile 1) had a higher rate than those living in high-income communities (312.8 per 1,000 compared with 266.1 per 1,000).
• In 2006, Medicare beneficiaries (348.3 per 1,000), Medicaid beneficiaries (307.3 per 1,000), and people without insurance (321.3 per 1,000) had higher rates of hospital admissions for perforated appendix than people with private insurance (270.1 per 1,000).

Mental Health Care and Substance Abuse Treatment

Mental Health Care

Although the prevalence of mental disorders for racial and ethnic minorities in the United States is similar to that for Whites,³¹ minorities have less access to mental health care and are less likely to receive needed services.³² Differences in receipt of services also may reflect, in part, variation in preferences and cultural attitudes toward mental health.³²

Figure 3.15. Adults who received mental health treatment or counseling in the last 12 months, by race, ethnicity, and education, 2003-2007

   

Key: AI/AN = American Indian or Alaska Native.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003-2007.

Denominator: U.S. population age 18 and over.

Note: Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders.

• From 2003 to 2007, the gap between Blacks and Whites increased (Figure 3.15). In 2007, Blacks were significantly less likely than Whites to receive mental health treatment or counseling (6.8% compared with 14.7%).
• During this period, the gap between AI/ANs and Whites remained the same. In 2007, AI/ANs were less likely than Whites to receive mental health treatment or counseling (9.4% compared with 14.7%).
• The gap between Asians and Whites in the percentage of people who received mental health treatment or counseling remained the same. In 2007, the percentage of Asians was less than one-third of the percentage of Whites (3.9% compared with 14.7%).
• The gap between Hispanics and non-Hispanic Whites increased. In 2007, the percentage of Hispanics was less than half that of non-Hispanic Whites (7.3% compared with 16.0%).
• The gap in mental health service use between people with less than a high school education and people with some college education remained the same. In 2007, the percentage was lower for people with less than a high school education (12.3%) and for high school graduates (12.5%) than for people with some college education (14.0%).

Substance Abuse Treatment

In 2006, about 17 million Americans age 12 and over acknowledged being heavy alcohol drinkers, and about 57 million acknowledged having had a recent binge drinking episode.³³ About 20.4 million people age 12 and over were illicit drug users, and about 72.9 million reported recent use of a tobacco product.³³ In 2001, an estimated $18 billion was devoted to treatment of substance use disorders. This amount constituted 1.3% of all health care spending.³⁴

Racial, ethnic, and socioeconomic differences in substance abuse treatment³¹ may, in part, reflect variation in preferences and cultural attitudes toward substance abuse.

Below is a measure of receipt of illicit drug or alcohol treatment services; it should be noted that differences in the rates could be influenced not only by differing treatment rates but also by varying levels of prevalence.

Figure 3.16. People age 12 and over who received any treatment for illicit drug or alcohol abuse in the last 12 months, by race, ethnicity, and education, 2003-2007

         

Key: AI/AN = American Indian or Alaska Native; NHOPI = Native Hawaiian or Other Pacific Islander.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003-2007.

Denominator: U.S. population age 12 and over.

Note: Data were insufficient for this analysis for Asians and NHOPIs in 2007 and NHOPIs in 2004.

• From 2003 to 2007, the gap between Blacks and Whites in the percentage of people age 12 and over who received any treatment for illicit drug or alcohol abuse remained the same (Figure 3.16). In 2007, the percentage was higher for Blacks than for Whites (2.3% compared with 1.5%).
• From 2003 to 2007, the gap between AI/ANs and Whites in the percentage of people age 12 and over who received any treatment for illicit drug or alcohol abuse remained the same. In 2007, the percentage was more than two times as high for AI/ANs as for Whites (3.5% compared with 1.5%).
• In 2007, the percentage was lower for Hispanics than for non-Hispanic Whites (1.1% compared with 1.6%).
• In 2007, the percentage was more than two times as high for people with less than a high school education compared with people with some college education (2.6% compared with 1.0%).

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Summary Tables

Table 3.1a. Racial and Ethnic Differences in Facilitators and Barriers to Health Care

Core Report Measure	Racial Differencei					Ethnic Differenceii
	Black	Asian	NHOPI	AI/AN	More than 1 Race	Hispanic
Health Insurance Coverage
People under age 65 with health insuranceiii	=	=	=	↓	=	↓
People under age 65 who were uninsured all yeariv	=	=	=	=	=	↓
Usual Source of Care
People with a specific source of ongoing careiii	=	=		=	=	↓
People with a usual primary care provideriv	↓	↓	=	=	=	↓
People without a usual source of care who indicated a financial or insurance reason for not having a source of careiv	↑	=			=	↓
Patient Perceptions of Need
People who were unable to get or delayed in getting needed careiv	=	↑		↓	↓	↑

ⁱ Compared with Whites.
ⁱⁱ Compared with non-Hispanic Whites.
ⁱⁱⁱ Source: National Health Interview Survey, 2007.
^iv Source: Medical Expenditure Panel Survey, 2006.

Key NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Key to Symbols Used in Access to Health Care Tables: = Group and comparison group have about same access to health care. ↑ Group has better access to health care than the comparison group. ↓ Group has worse access to health care than the comparison group. Blank cell: Reliable estimate for group could not be made.

Table 3.1b. Socioeconomic Differences in Facilitators and Barriers to Health Care

Core Report Measure	Income Differencei			Educational Differenceii		Ethnic Differenceiii
	<100%	100 199%	200 399%	<HS	HS Grad	Uninsured
Health Insurance Coverage
People under age 65 with health insuranceiv	↓	↓	↑	↓	↓
People under age 65 who were uninsured all yearv	↓	↓	↑	↓	↓
Usual Source of Care
People with a specific source of ongoing careiv	↓	↓	↑	↓	↓	↓
People with a usual primary care providerv	↓	↓	↓	↓	=	↓
People without a usual source of care who indicated a financial or insurance reason for not having a source of careiv	↓	↓	↑	↓	↓	↓
Patient Perceptions of Need
People who were unable to get or delayed in getting needed carev	↓	↓	↓	↓	↓	↓

ⁱ Compared with persons with family incomes 400% of Federal poverty thresholds or above.
ⁱⁱ Compared with persons with any college education.
ⁱⁱⁱ Compared with persons under 65 with any private health insurance.
^iv Source: National Health Interview Survey, 2007.
^v Source: Medical Expenditure Panel Survey, 2006.

Key HS=High school.

Key to Symbols Used in Access to Health Care Tables: = Group and comparison group have about same access to health care. ↑ Group has better access to health care than the comparison group. ↓ Group has worse access to health care than the comparison group. Blank cell: Reliable estimate for group could not be made.

Table 3.2a. Racial and Ethnic Differences in Health Care Utilization

Core Report Measure	Racial Differencei					Ethnic Differenceii
	Black	Asian	NHOPI	AI/AN	More than 1 Race	Hispanic
General Medical Care
People who had a dental visit in the calendar year iii	↓	↓	↑	↓	↓	↓
Avoidable Admissions
Perforated appendixes per 1,000 admissions with appendicitisiv	↓	=				=
Mental Health Care and Substance Abuse Treatment
Adults who received mental health treatment or counseling in the last 12 monthsv	=	↓		=	=	=
People age 12 and over who received any treatment for illicit drug or alcohol abuse in the last 12 monthsv	=			=	=	=

ⁱ Compared with Whites.
ⁱⁱ Compared with non-Hispanic Whites.
ⁱⁱⁱ Source: Medical Expenditure Panel Survey, 2006.
^iv Source: HCUP SID disparities analysis file, 2006. This source categorizes race/ethnicity very differently from other sources. Race/ethnicity information is categorized as a single item: Non-Hispanic White, Non-Hispanic Black, Hispanic, Asian or Pacific Islander. These contrasts compare each group with non-Hispanic Whites.
^v Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2007.

Key NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.

Key to Symbols Used in Health Care Utilization Tables: = Group and comparison group receive about the same amount of health care. ↑ Group receives more health care than the comparison group. ↓ Group receives less health care than the comparison group. Blank cell: Reliable estimate for group could not be made.

Table 3.2b. Socioeconomic Differences in Health Care Utilization

Core Report Measure	Income Differencei			Educational Differenceii		Insurance Differenceiii
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
General Medical Care
People who had a dental visit in the calendar year iv	↓	↓	↑	↓	↓	↓
Avoidable Admissions
Perforated appendixes per 1,000 admissions with appendicitisv	↓	=	↑			↓
Mental Health Care and Substance Abuse Treatment
Adults who received mental health treatment or counseling in the last 12 months v				=	=
People age 12 and over who received any treatment for illicit drug or alcohol abuse in the last 12 monthsv				=	=

ⁱ Compared with persons with family incomes 400% of Federal poverty threshold or above.
ⁱⁱ Compared with persons with any college education.
ⁱⁱⁱ Compared with persons under 65 with any private health insurance.
^iv Source: Medical Expenditure Panel Survey, 2006.
^v Source: HCUP SID disparities analysis file, 2006. This source categorizes race/ethnicity very differently from other sources. Race/ethnicity informationis categorized as a single item: Non-Hispanic White, Non-Hispanic Black, Hispanic, Asian or Pacific Islander. These contrasts compare each group with non-Hispanic Whites.
^vi Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2007. Insurance disparities were not analyzed.

Key HS = high school.

Key to Symbols Used in Health Care Utilization Tables: = Group and comparison group receive about same amount of health care. ↑ Group receives more health care than the comparison group. ↓ Group receives less health care than the comparison group. Blank cell: Reliable estimate for group could not be made.

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