The study identified a set of 46 necessary care indicators associated with minimum standards of acceptable care and avoidable health problems, then analyzed the 1994-1996 medical claim forms of more than 345,000 randomly selected Medicare patients in the light of these criteria. Results showed that beneficiaries received indicated care for many of these categories less than two thirds of the time. For example, fewer than half of Medicare patients with diabetes receive annual vision tests.

African-Americans scored significantly worse than whites on 16 care indicators, although better on two. Residents of impoverished areas scored significantly lower than nonresidents on 17 indicators, higher on only one. Patients living in federally-defined Health Professional Shortage Areas scored significantly lower on 16 indicators, higher on none. For example, 63 percent of white women with a history of breast cancer had an annual mammogram compared to 55 percent of African-American women.

"Monitoring under-use of needed care is essential in this period of unprecedented rapid changes in the health care delivery system, but traditional methods are either expensive or clinically unconvincing. No matter how we choose to reform Medicare, tracking under-use will be a crucial activity," observed lead author Dr. Steven Asch, the study team's principal investigator. "Our work shows that it is possible to track under-use on a valid and efficient basis using readily available administrative data to focus further evaluation and quality improvement efforts," he added. Asch, an internist is associated with RAND, the Greater Los Angeles VA Health Care System and UCLA.

Co-author Robert Brook, M.D., the director of RAND's health program, said, "This is a key step in developing a continuous quality improvement system. It could also be a first step in developing a national report on quality of medical care for the U.S. population age 65 and older."

The study was funded by the Physician Payment Review Commission (now the Medicare Payment Advisory Commission), an independent federal body that advises Congress on Medicare, with support from VA's Health Services Research and Development program. RAND is a nonprofit institution that helps improve policy and decision-making through research and analysis.