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,^1,18 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.¹⁹

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 workers²⁰ provided about 960 million office visits²¹ and 673 million hospital outpatient visits²² and treated 37 million hospitalized patients²³ and 1.4 million nursing home residents.²³ About 70% of the civilian noninstitutionalized population visit a medical provider's office or outpatient department, about 60% receive a prescription medicine, and about 40% visit a dental provider each year.²⁴

National health expenditures totaled over $2 trillion in fiscal year 2006, nearly double those of a decade earlier.²⁵ Health expenditures among the civilian noninstitutionalized population in America are extremely concentrated, with 5% of the population accounting for 55% of outlays.²⁶ In addition, a study using earlier data estimated that as much as $420 billion a year—almost one-third of all health care expenditures—are the result of low-quality care, including overuse, misuse, and waste.²⁷

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. In this section, findings related to dental care, emergency department visits, and mental health care and substance abuse treatment are highlighted.

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.²⁸

Figure 3.10. People who had a dental visit in the calendar year, by race (top left), ethnicity (top right), and income (bottom left), 2002-2005

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, 2002-2005.

Reference population: 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 2005 across racial, ethnic, or income categories (Figure 3.10).
• From 2002 to 2005, the gap between Blacks and Whites in the percentage of people with a dental visit in the calendar year remained the same. In 2005, the percentage was significantly lower for Blacks than for Whites (30.5% compared with 45.7%).
• During the same period, the gap between Hispanics and non-Hispanic Whites remained the same. In 2005, the percentage was significantly lower for Hispanics than for non-Hispanic Whites (27.8% compared with 49.5%).
• In 2005, the gap between poor people and high-income people remained the same. The percentage was significantly lower for poor (27.1%), near-poor (29.7%), and middle-income people (41.5%) than for high-income people (56.9%).
• Only high-income people met the Healthy People 2010 target of 56% of people with a dental visit in the past year.

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

Figure 3.11. People who had a dental visit in the calendar year, by race (left) and ethnicity (right), stratified by income, 2005

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.

Reference population: 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 3.11).
• In all income categories, Blacks were significantly less likely than Whites to have had a dental visit in the calendar year (poor, 22.8% for Blacks versus 29.1% for Whites; near poor, 25.2% for Blacks versus 30.7% for Whites; middle income, 32.3% for Blacks versus 43.0% for Whites; and high income, 43.1% for Blacks versus 58.7% for Whites).
• Hispanics at every income level were significantly less likely than non-Hispanic Whites to have had a dental visit (poor, 22.9% of Hispanics versus 32.3% of non-Hispanic Whites; near poor, 20.8% of Hispanics versus 34.9% of non-Hispanic Whites; middle income, 29.5% of Hispanics versus 45.8% of non-Hispanic Whites; high income, 43.1% of Hispanics versus 60.0% 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 care is urgent often results in poorer health outcomes and increased health care costs.

Figure 3.12. Emergency department visits per 100 population in the calendar year, by race, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006.

Denominator: Civilian noninstitutionalized population, all ages.

Note: Data did not meet criteria for statistical reliability for Asians (for data years 1997-1998, 1999-2000, and 2003-2004) and Native Hawaiians and Other Pacific Islanders.

• From 1997-1998 to 2005-2006, the rate of ED visits remained the same except for Blacks (Figure 3.12).
• During this period, the gap between Blacks and Whites increased. In 2005-2006, the rate of ED visits was more than twice as high for Blacks as for Whites (74.5 per 100 population compared with 36.5 per 100 population).
• In 2005-2006, the rate of ED visits was lower for Asians than for Whites (17.7 per 100 population compared with 36.5 per 100 population).
• In 2005-2006, the rate of ED visits was higher for females than for males (42.5 per 100 population compared with 37.5 per 100 population; data not shown).

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.²⁹ For example, better access to care should reduce the percentage of appendicitis admissions in which rupture has already occurred.

Figure 3.13. Perforated appendixes per 1,000 admissions with appendicitis, by race/ethnicity (left) and area income (median income of ZIP Code of residence) (right), 2001-2005

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, 2001-2005.

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

Note: White, Black, and API are non-Hispanic groups. Numeric income categories are used instead of the NHDR's usual descriptive categories because that is how data are collected for this measure. 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 23 States that have 64% of the U.S. resident population. Data for American Indians and Alaska Natives from NPIRS can be found in Chapter 4 but is not collected by this data source.

• From 2001 to 2005, the gap between Blacks and Whites in the rate of hospital admissions for perforated appendix decreased (Figure 3.13). In 2005, Blacks had a higher rate than Whites (317.3 per 1,000 compared with 282.7 per 1,000).
• In 2005, APIs and Whites were not significantly different in the rate of hospital admissions for perforated appendix.
• The gap between Hispanics and non-Hispanic Whites was eliminated. In 2005, there was no statistically significant difference between Hispanics and Whites (283.2 per 1,000 compared with 282.7 per 1,000).
• From 2001 to 2005, the gap between people living in poor communities and those living in high-income communities in the rate of hospital admissions for perforated appendix increased. In 2005, people living in poor communities had a higher rate than those living in high-income communities (308.8 per 1,000 compared with 265.8 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,³⁰ minorities have less access to mental health care and are less likely to receive needed services.³¹ These differences may reflect, in part, variation in preferences and cultural attitudes toward mental health.³²

Figure 3.14. Adults who received mental health treatment or counseling in the last 12 months, by race (top left), ethnicity (top right), and education (bottom left), 2003-2006

Key AI/AN = American Indian or Alaska Native.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003-2006.

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

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

• From 2003 to 2006, the gap between Blacks and Whites remained the same (Figure 3.14). In 2006, Blacks were significantly less likely than Whites to receive mental health treatment or counseling (7.4% compared with 14.0%).
• In 2006, there was no statistically significant difference between AI/ANs and Whites.
• The gap between Asians and Whites in the percentage of people who received mental health treatment or counseling remained the same. In 2006, the percentage of Asians was less than half that of Whites (5.6% compared with 14.0%).
• The gap between Hispanics and non-Hispanic Whites remained the same. In 2006, the percentage of Hispanics was less than half that of non-Hispanic Whites (7.0% compared with 15.2%).
• 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 2006, the percentage was lower for people with less than a high school education (10.9%) and for people with a high school education (11.8%) than for people with some college education (14.2%).
• In 2006, there were no statistically significant differences between people of different income levels in the receipt of mental health treatment or counseling (data not shown).

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.³² 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.³³

Racial, ethnic, and socioeconomic differences in substance abuse treatment³² may, in part, reflect variation in preferences and cultural attitudes toward mental health and substance abuse.

Figure 3.15. People age 12 and over who received any treatment for illicit drug or alcohol abuse in the last 12 months, by race (top left), ethnicity (top right), and education (bottom left), 2003-2006

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, 2003-2006.

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

Note: The figure reflects both prevalence and treatment; variations in prevalence likely have an effect on racial and ethnic differences in treatment.

• From 2003 to 2006, 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 (Figure 3.15). In 2005, the percentage was more than two times higher for AI/ANs than for Whites (3.8% compared with 1.6%).
• During this period, the gap between Asians and Whites in the percentage of people age 12 and over who received drug or alcohol abuse treatment remained the same. In 2006, the percentage of people age 12 and over who received any illicit drug or alcohol abuse treatment was lower for Asians than for Whites (0.4% compared with 1.6%).
• During this period, there were no significant differences between Hispanics and non-Hispanic Whites.
• The gap between people with less than a high school education and people with some college education increased. In 2006, the percentage was more than two times higher for people with less than a high school education than for people with some college education (3.2% compared with 1.1%).

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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	>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	↓				↓	↓
People unable to get or delayed in getting needed care due to financial or insurance reasonsiv	=	=			↓	↓

ⁱ Compared with Whites.
ⁱⁱ Compared with non-Hispanic Whites.
ⁱⁱⁱ Source: National Health Interview Survey, 2006.
^iv Source: Medical Expenditure Panel Survey, 2005.

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	↓	↓	↑	↓	↓	↓
People unable to get or delayed in getting needed care due to financial or insurance reasonsv	↓	↓	↑	↓	=	↓

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, 2006.
^v Source: Medical Expenditure Panel Survey, 2005.

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	<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 older 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, 2005.
^iv Source: HCUP SID disparities analysis file, 2005. 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, 2006.

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 appendicitis	↓	↓	↑			↓
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 older 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, 2005.
^v Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2006. 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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