Survey Suggests Medical Care Spending Not Related to Perceived Quality of Care

Newswise — A survey of Medicare beneficiaries suggests that more regional spending on medical care does not improve patients' perceptions of the medical care they receive, according to a study in the May 28 issue of JAMA.

It has been documented that per capita expenditures for Medicare beneficiaries vary widely from area to area across the United States, and that differences in health status do not account for these variations. Little is known about whether beneficiaries residing in low-expenditure regions perceive receiving lower-quality of care than those in high-expenditure regions, according to background information in the article.

Floyd J. Fowler Jr., Ph.D., of the University of Massachusetts Boston, and colleagues report results of a detailed survey of Medicare patients which included a number of questions about the perceptions of quality of health care from the patients' own perspectives. The researchers compared these answers with the overall level of per capita expenditure within various regions in the U.S., to evaluate whether more spending leads to a more positive patient experience with the health care system.

Each respondent (answers from 2,515 patients were used for this study) was allocated to one of five quintiles, depending on sex, average age, and race-adjusted per capita Medicare expenditures based on Centers for Medicare & Medicaid Services claims data. The survey included three questions about perceived unmet need for care, four questions about the perceived quality of ambulatory care and three questions rating the perceived quality of overall care.

The researchers found that per capita expenditures were highly related to receiving more medical care, such as average number of ambulatory visits to physicians in the past year and more cardiac tests (respondents reporting receiving tests in past year, 40.1 percent [lowest average expenditures quintile] to 63.5 percent [highest average expenditures quintile]). However, 7 of the 10 measures of perceived quality, including perceived unmet needs for tests and treatment (respondents reporting unmet needs, 3.9 percent to 5.0 percent) and spending enough time with physicians (respondents reporting adequate time, 88.7 percent to 87.0 percent), were unrelated to expenditures, while the overall rating of perceived quality of care was higher in the lower-expenditure areas (respondents reporting overall care rating of 9 or 10, 63.3 percent to 55.4 percent).

"On average, those in the lower-expenditure areas reported no more perceived unmet needs for care and a perceived quality of ambulatory care similar to that in high-expenditure areas; furthermore, they rated the overall quality of their health care at least as highly as those in the high-expenditure areas," the authors write.(JAMA. 2008;299[20]:2406-2412. Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Spending on Medical Care " More is Better?

In an accompanying editorial, Gerard F. Anderson, Ph.D., and Kalipso Chalkidou, M.D., Ph.D., of the Johns Hopkins Bloomberg School of Public Health, Baltimore, comment on the study in this week's JAMA regarding Medicare expenditures and perceived quality of care.

"The article by Fowler et al adds to the discussion concerning whether the economic principles of 'more is better,' diminishing returns, and comparisons with others apply in health care. When patients are able to access good-quality objective information on the risks and benefits of the various treatment alternatives, they do not necessarily choose more aggressive or more costly interventions. Currently, the United States spends more than twice as much as most other industrialized countries on health care services, some regions of the United States spend twice as much as other regions of the country, and some institutions or clinicians are twice as expensive as others. In terms of outcomes and satisfaction, the United States may have reached the position of diminishing returns for spending on medical care." (JAMA. 2008;299[20]:2444-2445. Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

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