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Research Questions

  1. What was the average utilization of health care services by Medicare Advantage enrollees for 2015 and 2016 dates of services for the following five service categories: inpatient hospital stays, outpatient hospital visits, emergency department visits, other outpatient facility visits, and professional services visits?
  2. Has average utilization of health care services by Medicare Advantage enrollees changed from 2015 to 2016?

This report describes analytical methodologies, estimates, and technical considerations related to the measurement of health care utilization in Medicare Part C encounter data (ED) submitted by organizations offering Medicare Advantage plans to Medicare beneficiaries. The primary aim of the report is to provide technical details for researchers on the structure and scope of ED and on the methodological steps and analytical decisions necessary to assess utilization of health care services using ED. The authors identify key considerations related to enrollment, differences in ED and Medicare claims data, and decisions that researchers must make about data field selection.

From 2015 to 2016, there was a slight decrease in inpatient hospital stays (from 0.231 to 0.225 per enrollee) and a slight increase in professional visits (from 21.095 to 21.292 per enrollee). Outpatient facility visits, emergency department visits, and other outpatient facility visits increased slightly.

Key Findings

Utilization in 2015

  • There was an average of 0.231 inpatient hospital stays per beneficiary.
  • There was a higher number of outpatient hospital visits than inpatient hospital stays, at 3.397 per beneficiary on average.
  • There was an average of 0.594 emergency department visits per beneficiary.
  • There was an average of 0.609 other outpatient facility visits per beneficiary. This utilization category includes visits to outpatient facility settings other than outpatient hospital or emergency departments, such as ambulatory surgery centers and federally qualified health centers.
  • There was an average of 21.095 professional visits per beneficiary. Professional services include services provided by physicians, other practitioners, and suppliers (e.g., laboratories) across all places of service.

Changes in utilization from 2015 to 2016

  • There was a slight decrease in inpatient hospital stays (from 0.231 to 0.225 per enrollee) and a slight increase in professional visits (from 21.095 to 21.292 per enrollee).
  • Outpatient facility visits, emergency department visits, and other outpatient facility visits increased slightly.
  • While all of the 2015 to 2016 changes were statistically significant, the magnitudes of the changes were very small relative to the standard deviation of each measure.

Research conducted by

The research described in this report was funded by the Centers for Medicare & Medicaid Services (Centers for Medicare & Medicaid Services, Medicare Plan Payment Group), and conducted by the Payment, Cost, and Coverage Program within RAND Health Care.

This report is part of the RAND Corporation research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.