People age 65 years and older use health services more often and with greater intensity than the younger population. Within the older population itself, the highest service use is seen for those with disabilities and poor health (Hahn and Lefkowitz, 1992; Wolinsky et al., 1983). This chapter describes service use among the community-resident participants in the Women's Health and Aging Study (WHAS), all of whom are moderately to severely disabled.
For younger people, insurance coverage is a major determinant of access to medical care (Aday et al., 1984; Lefkowitz and Monheit, 1991). Among people age 65 years and older, however, 95 to 97 percent have coverage for basic health care provided through the Medicare program. Since Medicare enrollment files were used to generate the WHAS sampling frame, all study participants have Medicare coverage. There is variation, however, in public and private coverage that supplements Medicare. This supplemental coverage is significant since it both reduces out-of-pocket costs and covers services that are not part of the Medicare benefit package.
Some elderly people with incomes below the poverty level who meet means testing requirements may obtain Medicaid coverage. One-fifth of the older disabled women in the WHAS were covered by Medicaid (Table 6.1) and another 2 percent reported that some other public assistance program helped pay for medical care. National data indicate that from 8 to 12 percent of persons age 65 years and older have Medicaid as well as Medicare coverage (Chulis et al., 1993). Medicaid coverage is two to three times higher, however, among persons who report poor health (26 percent in Chulis et al., 1993). Poor health was more commonly reported among women eligible for the WHAS than among physically able women (see Chapter 1, Table 1.2). Among older disabled women, there is no clear relationship between Medicaid coverage and severity of disability, although there was a slight decline in reported coverage with increasing age.
Two-thirds (67 percent) of WHAS respondents reported that they had private supplemental coverage, in addition to Medicare, that paid for hospital or physician care. The 1987 National Medical Care Expenditure Survey (NMES) and the 1991 Medicare Current Beneficiary Survey (MCBS) found that 75 percent of people age 65 years and older nationwide had private supplemental coverage (Chulis et al., 1993). Among people in poor health, this type of coverage was lower (around 50 percent in the MCBS), in contrast to their higher Medicaid coverage. Among the most severely disabled-those women receiving assistance with activities of daily living (ADLs)-53 percent reported having supplemental coverage, a lower percentage than among less severely disabled women (65 percent of moderately disabled women and 74 percent of those who had difficulty with ADLs but received no help). Supplemental insurance coverage for prescription medicines was much lower, reported by only a little more than one-third of older disabled women. Among women 85 years and older only one-quarter reported having insurance that helped pay for medications.
Three-quarters of the women sampled indicated they never had a problem affording the kind of medical care they (and their husbands) should have. Women in the oldest age group were more likely to say they never had a problem than those in the youngest age group (87 and 72 percent, respectively). Overall 9 percent said they had a problem affording care fairly often or very often. There was no clear relationship, however, between problems affording care and disability level.
One-quarter of these older disabled women reported they had been hospitalized overnight during the past year (Table 6.2). In calendar year 1991, 17.5 percent of all elderly Medicare beneficiaries were hospitalized at least once (Chulis et al., 1993). The average length of hospital stay was 11 days for women in the WHAS population who had been hospitalized. The median was considerably shorter, 6 days, indicating that this sample contained some women who had very long stays. Average length of stay per person ranged from 8 days for moderately disabled women to 16 days for the most severely disabled.
Only 1 percent of these older disabled women had been in a nursing home in the past year, staying on average 3 to 4 weeks (mean, 28 days; median, 21 days). The proportion with a recent nursing home stay ranged from 0.1 percent for the moderately disabled to 3.2 percent for women who received help with ADLs. Many studies have documented a relationship between ADL disability and nursing home use (Branch and Jette, 1982; Murtaugh et al., 1990; Salive et al., 1993). A population of functionally limited women should be expected to have higher rates of nursing home admission over time than a representative cross section of older women. At baseline only community-resident women were recruited into the WHAS, so the virtual absence of recent nursing home use is not surprising.
Nearly 9 out of 10 participants (89 percent) had seen a physician in the 6 months prior to the baseline interview, four times on average (Table 6.3). This figure is consistent with national estimates of physician contact for community-resident women age 65 years and older (Benson and Marano, 1994). Among older disabled women, there was little variation by age or functional status in likelihood of a physician visit, although mean number of visits in 6 months was lower for the oldest women (3.0 compared with 4.2 for women in the two younger groups). Virtually all the study participants indicated they had a regular source of care for illness or health advice (96 percent). This is consistent with national data from the NMES, which reported that 90 percent of those age 65 years and older reported a usual source of medical care (Cornelius et al., 1991).
Slightly over half of these older disabled women reported having a flu shot (influenza vaccination) in the past year, with little variation according to age and disability. Medicare began covering flu shots for elderly beneficiaries effective May 1, 1993, which was during the WHAS enrollment period (November 1992-February 1995). Medicare coverage is likely to substantially increase influenza vaccination rates among older people in the future. In 1991, 41.5 percent of older women reported receiving a flu shot in the previous year and rates have been increasing over time (Centers for Disease Control and Prevention, 1995).
The use of health care professionals other than physicians is generally low among older disabled women (Table 6.4). Fewer than 5 percent made use of an occupational therapist, a speech therapist, a hearing therapist, or a mental health professional in the 6 months prior to the baseline interview. Use of physical therapy and visiting nurse or home health services was somewhat more common. Fourteen percent reported physical therapy and 13 percent reported in-home assistance from a visiting nurse, home health aide, or nurse's aide. The most disabled women were much more likely than the less disabled women to use the services of health professionals other than physicians. Over a 6-month period, they were about twice as likely to receive physical therapy, occupational therapy, speech therapy, or mental health services. Almost 35 percent of women receiving ADL help used the services of a visiting nurse, home health aide, or nurse's aide.
Intensity of service use is reflected in the mean and median number of visits. Among users of physical or occupational therapy, which are rehabilitative services, the mean number of visits in a 6-month period was high (14 and 15 visits, respectively). The median number of visits for physical therapy was substantially lower, indicating the presence of some very high users of these services. Similarly, although very few women used mental health services, those that did averaged about five visits per person in the previous 6 months. For most of these services, the intensity of use was greatest for the most disabled users.
As would be expected among older women with functional limitations, the use of health services was relatively high. In most instances, these women used more health services than those of similar age in the general population. The somewhat higher coverage by Medicaid and lower supplemental private coverage is also consistent with what might be expected in a more disabled population. The urban east coast location of the study population and higher proportion of minority and poorly educated women also may influence patterns of service use and coverage. It is also important to note that these data on service use are based on self-report. For future studies of health care utilization by this cohort of older disabled women, more complete information will be available from Medicare claims files.
Aday LA, Fleming GV, Andersen R. (1984). Access to Medical Care in the U.S.: Who Has It, Who Doesn't. Pluribus Press and Center for Health Administration Studies, Univ. of Chicago.
Benson V, Marano MA. (1994). Current estimates from the National Health Interview Survey. Vital Health Stat 10(189).
Branch LG, Jette AM. (1982). A prospective study of long-term care institutionalization among the aged. Am J Public Health 72:1373-1379.
Centers for Disease Control and Prevention. (1995). Influenza and pneumococcal vaccination coverage levels among persons aged � 65 years. MMWR 44:506-515.
Chulis GS, Eppig FJ, Hogan MO, Waldo DR, Arnett RH. (1993). Health insurance and the elderly: Data from MCBS. Health Care Financing Rev 14: 163-181.
Cornelius L, Beauregard K, Cohen J. (1991). Usual sources of medical care and their characteristics. National Medical Expenditure Survey Research Findings No. 11. Agency for Health Care Policy and Research. DHHS Pub. No. (PHS) 91-0042. Rockville, MD: Public Health Service.
Hahn B, Lefkowitz D. (1992). Annual expenses and sources of payment for health care services. National Medical Expenditure Survey Research Findings No. 14. Agency for Health Care Policy and Research. DHHS Pub. No. (PHS) 93-0007. Rockville, MD: Public Health Service.
Lefkowitz D, Monheit A. (1991). Health insurance, use of health services, and health care expenditures. National Medical Expenditure Survey Research Findings No. 12. Agency for Health Care Policy and Research. DHHS Pub. No. 92-0017. Rockville, MD: Public Health Service.
Murtaugh CM, Kemper P, Spillman BC. (1990). Risk of nursing home use in later life. Med Care 28:951-962.
Salive ME, Collins KS, Foley DJ, George LK. (1993). Predictors of nursing home admission in a biracial population. Am J Public Health 83:1765-1767.
Wolinsky FD, Coe RM, Miller DK, Prendergast JM, Creel MJ, Chavez MN. (1983). Health services utilization among the noninstitutionalized elderly. J Health Soc Behav 24:325-337.