Medicare beneficiaries rate their medical care: new data from the MCBS (Medicare Current Beneficiary Survey).

The Medicare Current Beneficiary Survey (MCBS) contains a wealth of information about the people whose care is financed by the program. This article examines their satisfaction with medical care received and explores the relationship of these attitudes with the characteristics of subgroups of the enrolled population. Satisfaction with medical care among Medicare beneficiaries is found to be generally high (80-90 percent). Disabled Medicare beneficiaries are less satisfied than the aged, and health maintenance organization (HMO) enrollees less satisfied than fee-for-service (FFS) patients. Others with lower-than-average satisfaction are people with poorer health status, those covered by Medicaid, and those without supplementary insurance.

Introduction

This article presents and explores information on the satisfaction of Medicare beneficiaries with the medical care they receive. These new data combine information from claims and administrative files with extensive survey data from a large nationwide sample of beneficiaries.

The MCBS is a continuous personal-interview survey of a panel of 12,000 Medicare beneficiaries which began data collection in 1991. It was established by the Health Care Financing Administration (HCFA) in response to the need for comprehensive data on use of care, costs, and insurance coverage for this defined population, regardless of whether the services are paid for by Medicare, other public or private insurance, or out of pocket. The sample includes both aged and disabled Medicare beneficiaries; these groups have the same program benefits but different population characteristics and health care needs. Sample members are interviewed in person or by proxy approximately every 4 months to acquire continuous data on services, costs, payments, and insurance coverage.

The typical length of a sample member's participation is 4 years. Adler (1994) provides a comprehensive profile of this survey.

In addition to health care financing data, the MCBS annually collects a variety of demographic, health status, and income information, as well as attitudes about medical care, sources of information, and access to care. The MCBS serves as a means for HCFA to better understand its clientele through both cross-sectional and longitudinal analyses.

Importance of Customer Satisfaction

Amid all the advances in the objective measurement of quality of medical care by expert criteria, the study of patient attitudes has taken on new prominence. Health care organizations have come to recognize client satisfaction as an important outcome of care. Patients are increasingly seen as customers who make choices; the ultimate outcome of all the organization's activities is seen as its effects on those customers. HCFA shares this customer-oriented concern and has taken initiatives to improve both the information Medicare beneficiaries have about the program and the knowledge that HCFA has about the needs of its clients and the impacts of its policies and procedures.

A second reason for the concern with client attitudes is the importance of patient attitudes in the clinical process. The patient is becoming recognized as a participant in maintaining and promoting his or her health. Studies have examined the importance of the patient's involvement in care and communication with providers in prevention of illness, adherence to regimens, continuity of care, malpractice litigation, disenrollment from health plans, and other behavioral issues (Aharony and Strasser, 1993). These factors are especially relevant among the Medicare population, where the high prevalence of chronic diseases makes self-management of care critical.

Descriptive Medicare Population Data

This section presents basic characteristics of the Medicare population, as measured by the MCBS. These dimensions will then be used to examine the distribution of satisfaction with medical care. The Round 7 data on which this analysis is based were collected between September 1 and December 31, 1993. In Round 7, interviews were completed for a total of 10,710 aged and 2,153 disabled sample persons, representing a total population of 30.5 million aged and 3.5 million disabled beneficiaries who were continuously enrolled in the program in 1993. Since satisfaction questions were limited to the 94 percent of program beneficiaries who live in the community, those living in long-term care (LTC) facilities are excluded from this analysis.

A basic distinction must be drawn between the aged and disabled populations served by Medicare. Almost all Americans who reach 65 years of age are eligible for Medicare Part A and entitled to purchase Part B insurance. Age, therefore, is the defining eligibility characteristic for those 65 years of age or over; 90 percent of the enrolled population is in this eligibility group.

The remaining 10 percent of beneficiaries are eligible for Medicare as a result of their disability. Though they are entitled to the same benefits as the aged, the basis of their eligibility is quite different. The Social Security Amendments of 1972 extended Medicare eligibility to the disabled under specific circumstances. Medicare eligibility for the disabled population is dependent on eligibility for income support under the Social Security Disability Insurance (SSDI) program. SSDI criteria refer both to inability to work and being related in certain ways to the labor force (i.e., disabled workers and their survivors and dependents). Those who qualify for SSDI must wait 5 months before being able to receive cash payments and an additional 2 years before being eligible for Medicare. About 75 percent of SSDI beneficiaries are enrolled in Medicare (Kochhar and Scott, 1995). Without further venturing into the complexities of SSDI, it is clear that disabled Medicare beneficiaries are a highly selected group, likely to have more severe disabilities of longer duration, and likely to have fewer financial resources, than the disabled population as a whole. Most of our analyses will consider the aged and disabled as distinct populations.

Figure 1 shows the distribution of chronic conditions among the Medicare aged and disabled populations. They are arrayed in order of their frequency among the aged to make the pattern of illness clearer. The chart shows that the Medicare disabled under 65 years of age have most of the same chronic diseases as the elderly in similar (or higher) proportions and that they have, in addition, substantial burdens of psychiatric disorder and mental retardation.

Figure 1

Distribution of Chronic Conditions Among Medicare Aged and Disabled Beneficiaries: Medicare Current Beneficiary Survey Round 7

1Responses were given in answer to the question, “Has a doctor ever told you you had [condition]?” Non-community residents have beendeleted from this analysis.

SOURCE: Health Care Financing Administration: Medicare Current Beneficiary Survey Round 7, September 1-December 31, 1993.

Table 1 shows the distribution of key demographic characteristics among aged and disabled Medicare beneficiaries. A discussion of each of these characteristics follows.

Table 1

Characteristics of Medicare Population Living in the Community: MCBS Round 7

Characteristic	All	Aged	Disabled
Number (Millions)	31.74	28.67	3.07
Total Percent	100	100	100
	Percent
Age
Under 45 Years	3.3	–	34.6
45-64 Years	6.3	–	65.4
65-69 Years	24.0	26.6	–
70-74 Years	26.5	29.4	–
75-79 Years	19.2	21.2	–
80-84 Years	12.3	13.6	–
85 Years or Over	8.3	9.2	–
Education
Grade School	15.2	14.9	18.3
Grade School Graduate	10.4	10.9	6.5
High School	16.2	15.8	19.8
High School Graduate	31.4	31.1	34.2
College	26.0	26.8	18.8
No Answer	0.7	0.6	2.4
Race/Ethnicity
Hispanic	5.7	5.2	10.1
Black/African-American	8.8	7.8	17.6
White	83.7	85.1	70.2
Other	1.9	1.8	2.2
Perceived Health Status
Excellent	17.3	18.4	6.8
Very Good	25.7	27.4	10.3
Good	29.7	30.2	24.8
Fair	18.7	17.3	32.3
Poor	8.1	6.3	25.2
No Answer	0.4	0.4	0.4
Functional Status
No ADLs or IADLs	76.2	77.7	62.0
IADL Only	4.7	4.5	5.9
1-2 ADLs	12.5	11.6	21.2
3-4 ADLs	4.3	4.0	7.2
5 or More ADLs	2.3	2.2	3.7
Usual Source of Care
Doctor's Office	69.7	70.9	59.1
Doctor's Clinic	8.9	9.0	8.9
Health Maintenance Organization	4.6	4.8	2.6
Hospital Outpatient or Emergency Department	3.4	2.8	8.7
Department of Veterans Affairs Clinic	1.8	1.6	3.5
Neighborhood/Family Health Center	0.9	0.8	2.0
Other Clinic	1.6	1.4	3.4
None	9.0	8.7	11.8
Insurance Coverage
Medicare and Private	76.5	81.0	34.3
Medicare and Medicaid	12.5	9.8	37.2
Medicare Only	9.5	7.9	24.6
Medicare and Public	1.5	1.3	3.8
Medicare Group Health Membership
No Membership	92.5	92.0	96.8
At Least 1 Month	7.5	8.0	3.2
Income
$5,000 or Less	7.3	6.7	12.7
$5,001-10,000	24.7	22.8	42.1
$10,001-15,000	19.0	19.4	15.5
$15,001-20,000	13.2	13.7	8.5
$20,001-25,000	10.0	10.5	5.2
$25,001-30,000	6.7	6.9	4.7
$30,001-35,000	4.7	4.8	4.0
$35,001-40,000	3.1	3.1	2.5
$40,001-45,000	1.9	2.0	1.0
$45,001-50,000	2.2	2.4	0.5
$50,001 or More	5.0	5.3	1.8
Not Reported	2.3	2.3	1.6

NOTES: MCBS is Medicare Current Beneficiary Survey. Includes only the continously enrolled. Non-community residents have been deleted from this analysis.

SOURCE: Health care Financing Administration: Medicare Current Beneficiary Survey, Round 7, September 1-December 31, 1993.

Age

Medicare is almost exclusively a program for adults. Because of the eligibility criteria, even the disabled group has very few beneficiaries under 21 years of age. At the other extreme of the age continuum, 2.6 million (8.3 percent of all beneficiaries) are among the oldest-old (85 years of age or over). Due to demographic patterns and increased longevity, both the number and proportion of the oldest-old are expected to grow. One-third of the disabled population is under 45 years of age, and two-thirds are between 45 and 64 years of age. The younger disabled are twice as likely to be mentally retarded or mentally ill than the older group (60 percent versus 30 percent), are likely to have lower income, be on Medicaid, and have lower rates of cancer, circulatory disease, and arthritis.

Education

Both the aged and disabled groups have relatively high educational levels, over 50 percent of each having graduated high school and/or attended college. The median number of school years completed among the 65 years of age or over population has risen steeply in the last 20 years (Adler, Kitchen, and Irion, 1987).

Race and Ethnicity

As part of the demographic portion of the interview, respondents are asked, “Which category best describes your race?” Answer categories are: American Indian; Asian or Pacific Islander; Black/African-American; White; and Other (specify). The next question asks “Are you of Hispanic origin?” In combining these variables for this analysis, Hispanics were grouped together regardless of their answer to the racial question.

The self-reported race and ethnicity of Medicare beneficiaries is overwhelmingly white, particularly among the aged group. About 8 percent of the aged and 18 percent of the disabled beneficiaries report that they are black/African-American, and 5 percent of the aged and 10 percent of the disabled report that they are Hispanic.

Health Status

MCBS respondents are asked the following question annually: “In general, compared to other people your age, would you say that your health is excellent, very good, good, fair, or poor?” Responses to this question, although it asks for a judgment rather than an objective fact, have been found to be predictive of objective health status, health behaviors, and even mortality (Idler, 1992).

Almost one-half of the aged Medicare beneficiaries (45.8 percent) rate their health as excellent or very good, a proportion which is remarkably stable across age groups. This finding presents a rather optimistic picture of the perceived health of the elderly. On the other hand, only 17 percent of the disabled rate their health as excellent or very good, while 57.8 percent rate their health as fair or poor.

Functional Status

The MCBS collects two well-documented measures of physical functioning (Wiener and Hanley, 1989). The first, activities of daily living (ADLs), includes such basic activities as bathing or showering, dressing, eating, getting in or out of bed or chairs, walking, or using the toilet. If respondents indicate difficulty with one of these, they are asked whether this is because of a health or physical problem, whether help is received from another person, whether someone stands by in case help is needed, and whether special equipment or aids are used.

The second scale, instrumental activities of daily living (IADLs), concerns activities which are more complex, including using the telephone, light housework, heavy housework, preparing meals, shopping, and managing money. These items are also followed up with questions about whether help is received.

A summary index of physical functioning was developed from these items according to the number of ADLs with which the beneficiary needed help and whether any IADLs required assistance. About 78 percent of the 65 years of age or over population report no ADL or IADL limitations. There are two primary reasons for this finding. First, the aged are more able than is commonly perceived. Second, the most severely disabled aged, those living in LTC facilities, are not considered in the current study (although they are included in the MCBS).

Disabled beneficiaries are somewhat less likely than the aged to have no measured impairments (62 percent). Thirty-two percent (versus 17 percent of the aged) have one or more ADL impairments. One might expect this rate to be higher, since the Medicare disabled have qualified for disability insurance payments; however, ADLs measure primarily physical functioning, while many of the Medicare disabled report mental illness or mental retardation.

Usual Source of Care

The MCBS sample is asked annually whether they have a particular medical person or clinic they usually go to when they are sick or require advice about their health; more than 9 out of 10 beneficiaries have such a regular source. Those who report a usual source of care are then asked a variety of questions, including the satisfaction items. Aged beneficiaries are more likely than the disabled to report a doctor's office or HMO as a usual source, and less likely to report a hospital outpatient or emergency department, veterans' clinic, neighborhood or family clinic, or other clinic. The remaining 9 percent report no usual source of care. This should not necessarily, however, be interpreted as a lack of access to care, since two-thirds of these people say they have no usual source because they are seldom or never sick.

Insurance Coverage

Over 80 percent of the aged have some form of private insurance coverage to supplement Medicare, whether that coverage is sponsored by an employer or purchased by the beneficiary (Chulis et al., 1993). Medicaid covers 10 percent, and other public programs cover just over 1 percent of the aged. Eight percent of the aged have no coverage other than Medicare. In contrast, only 34 percent of the disabled have private supplementary coverage. An additional 37 percent have Medicaid, 4 percent have other public insurance, and 25 percent have only Medicare.

Group Health Membership

Only 7.5 percent of Medicare beneficiaries were enrolled in prepaid health care plans, as measured by at least 1 month's payment recorded in 1993 Medicare administrative files. This proportion is expected to continue to grow. Disabled beneficiaries are considerably less likely than the aged to enroll in group health plans. The category includes several organizational types, but the predominant form is the risk-based HMO.

Income

The MCBS definition includes income from all sources for the sample person or the person and spouse. The distribution for the aged is concentrated (72 percent) under $25,000, with a long tail of higher incomes. The distribution for the disabled is considerably lower: About 55 percent have annual incomes (including disability payments) under $10,000.

Findings

Overall Satisfaction With Medical Care

The MCBS questionnaire includes several measures of satisfaction with medical care, each of which approaches the subject differently. First, an annual battery of eight items asks the respondent to rate “the medical care you have received over the past year from doctors and hospitals.” Potential responses are very satisfied, satisfied, unsatisfied, and very unsatisfied. Respondents also may answer “no experience” if the dimension was not a concern to them in the past year. These general satisfaction questions and the distribution of responses appear in Table 2.

Table 2

Satisfaction With Medical Care: MCBS Round 7

Measure of Satisfaction		Aged			Disabled
		Very Satisfied or Satisfied	Unsatisfied or Very Unsatisfied	No Experience	Very Satisfied or Satisfied	Unsatisfied or Very Unsatisfied	No Experience
		Percent
SC1.	Overall quality of the medical care you received in the last year	89.8	3.4	6.4	85.9	7.8	5.6
SC2.	Availability of medical care at night and on weekends	46.9	3.0	49.6	57.9	8.3	33.2
SC3.	Ease and convenience of getting to a doctor from where you live	90.1	5.2	4.3	83.5	11.8	4.3
SC4.	Out-of-pocket costs you paid for medical care	78.0	15.7	5.7	64.8	28.0	6.2
SC5.	Information given to you about what was wrong with you	86.8	6.1	6.5	82.4	10.8	5.7
SC6.	Follow-up care you received after an initial treatment or operation	80.6	3.1	15.9	80.4	6.4	12.4
SC7.	Concern of doctors for your overall health rather than just an isolated symptom or disease	86.3	5.6	7.4	82.5	10.2	6.2
SC8.	Getting all your medical care needs taken care of at the same location	82.7	4.6	11.9	79.0	10.3	10.1

Responses were given in answer to the question, “We're interested in how you feel about the medical care you have received over the past year from doctors and hospitals. Please tell me how satisfied you have been with the following [item].”

NOTE: MCBS is Medicare Current Beneficiary Survey. Non-community residents have been deleted from this analysis.

SOURCE: Health Care Financing Administration: Medicare Current Beneficiary Survey Round 7, September 1-December 31, 1993.

The proportion satisfied among the aged ranged from 78-90 percent (excluding the item on availability of care at night and on weekends, which about 50 percent of the aged rated not relevant). The range of satisfaction for the disabled was consistently lower, from 65-86 percent, again excluding the availability item.

Overall quality of care and ease and convenience of getting to the doctor were rated highest in both the aged and disabled groups. Cost of care was the least satisfactory for both groups: 28 percent of the disabled and 16 percent of the aged were unsatisfied or very unsatisfied with out-of-pocket costs.

Surveys generally find high levels of satisfaction with medical care, and the MCBS is no exception (Freeman et al., 1987). This often raises problems for researchers seeking causes and correlates of client satisfaction, since the range of this important outcome measure is constricted. Therefore it is important to include multiple measures of satisfaction, as the MCBS does, and to look for more subtle patterns of similarities and differences.

Open-Ended Questions

Immediately after this set of satisfaction items, all respondents were asked the open-ended question, “What things about the medical care you receive are you dissatisfied with?” Responses are summarized in Table 3. Fully 81 percent of the aged and 71 percent of the disabled beneficiaries, when asked directly, had no items of dissatisfaction to report.

Table 3

Primary Source of Dissatisfaction With Care: MCBS Round 7

Item	Aged	Disabled
	Percent
Total	100.0	100.0
Nothing	80.9	71.0
Cost of Health Care	4.3	6.5
Waiting Time	2.0	4.1
Doctor's Attitude	1.6	2.6
Thoroughness of Doctor	1.0	1.1
Services Covered	0.8	1.5
Doctor's Competence	0.6	0.8
Time Spent With Doctor	0.7	0.7
Paperwork	0.7	0.2
Inconvenient Location	0.5	1.1
Other	6.9	10.4

Responses were given in answer to the question, “What things about the medical care you receive are you dissatisfied with?”

NOTES: MCBS is Medicare Current Beneficiary Survey. Non-community residents have been deleted from this analysis.

SOURCE: Health Care Financing Administration: Medicare Current Beneficiary Survey Round 7, September 1-December 31, 1993.

This result is reinforced by its consistency with the next question, “What things about the medical services you receive need to be improved?” The results reported in Table 4 mirror those presented so far and reinforce the picture of a Medicare population that is overwhelmingly satisfied with medical care, with small proportions having a wide variety of complaints.

Table 4

Primary Factors Which Would Improve Medical Services: MCBS Round 7

Item	Aged	Disabled
	Percent
Total	100.0	100.0
Nothing	79.4	70.1
Reduce Cost	3.8	4.6
Reduce Waiting Time	3.1	4.0
Expand Coverage	1.8	3.4
Improve Billing Procedures	1.3	0.9
Improve Doctor's Attitude	0.8	1.1
Reduce Paperwork	0.8	0.5
Increase Time Spent With Patients	0.8	1.1
More Convenient Location	0.3	0.7
Other	7.9	13.6

Responses were given in answer to the question “What things about the medical services you receive need to be improved?”

NOTES: MCBS is Medicare Current Beneficiary Survey. Non-community residents have been deleted from this analysis.

SOURCE: Health Care Financing Administration: Medicare Current Beneficiary Survey Round 7, September 1-December 31, 1993

Satisfaction With Doctor

In order to characterize variations among subgroups of the Medicare population, we turn to a third set of measures of satisfaction which can be combined as additive scales or indices. The MCBS collects a battery of satisfaction items in the annual section about the usual source of medical care. The section begins with the question, “Is there a particular medical person or clinic you usually go to when you are sick or for advice about health?” It continues by asking about details of the place and the usual doctor.

This is followed by a series of questions about the usual doctor or doctors at the usual place of care: “Think about the care you receive from [named doctor or place]. For each statement, tell me whether you strongly agree, agree, disagree, or strongly disagree.” The specific items and their results are shown in Table 5.

Table 5

Satisfaction With Usual Source of Care: MCBS Round 7

Item		Aged(n = 25.9 Million)			Disabled(n = 2.7 Million)
		Strongly Agree or Agree	Strongly Disagree or Disagree	No Answer	Strongly Agree or Agree	Strongly Disagree or Disagree	No Answer
		Percent
Technical Items
US27.	Your doctor is very careful to check everything when examining you.	92.5	6.7	0.8	91.3	7.3	1.4
US28.	Your doctor is competent and well-trained.	97.2	1.1	1.7	94.7	2.5	2.9
US29.	Your doctor has a good understanding of your medical history.	94.7	3.6	1.6	91.5	6.3	2.3
US30.	Your doctor has a complete understanding of the things that are wrong with you.	92.5	5.4	2.1	87.3	10.3	2.5
US37.	You have great confidence in your doctor.	92.9	5.8	1.3	90.0	7.6	2.3
Interpersonal Items
*US31.	Your doctor often seems to be in a hurry.	15.1	84.4	0.6	17.3	81.4	1.3
*US32.	Your doctor often does not explain your medical problems to you.	10.5	88.7	0.9	13.4	85.3	1.3
*US33.	You often have health problems that should be discussed, but are not.	8.9	90.2	0.9	11.9	86.5	1.6
*US34.	Your doctor often acts as if she was doing you a favor by talking to you.	5.5	93.9	0.7	9.1	89.5	1.4
US35.	Your doctor tells you all you want to know about your condition and treatment.	91.3	7.9	0.8	87.1	11.1	1.8
US36.	Your doctor answers all your questions.	95.5	4.0	0.6	92.1	6.6	1.3

Sample excludes community residents with no usual source of care and non-community residents.

NOTES: MCBS is Medicare Current Beneficiary Survey. Starred items are asked in the negative; responses must be reversed when summed with other items.

SOURCE: Health Care Financing Administration: Medicare Current Beneficiary Survey Round 7, September 1-December 31, 1993.

These items relate to dimensions of satisfaction similar to those in Table 2, except that the referent is a particular doctor to which the sample person usually goes, rather than a general object (the medical care received in the past year). As in Table 2, the overwhelming majority of beneficiaries, both aged and disabled, agree with positive statements and disagree with negative statements about their usual doctor. For each item, the percent satisfied is lower among the disabled than the aged by 3 to 5 percentage points, but the lowest-scored item still shows over 80 percent approval.

In order to summarize the variation of satisfaction among subgroups, we developed two additive scales, the first including 5 items whose scores indicate the respondent's perception of the technical aspects of care, and the second including 6 items focusing on the respondent's perception of interpersonal aspects of care.

The summary scores discussed are the percent of each group deemed “satisfied” (i.e., who give positive responses to all or all but one of the items in each scale [a sum of 4 or 5 on the technical scale and 5 or 6 on the interpersonal scale]). We chose this method, rather than a mean score, due to the skewness of responses to most of the items. What we are interested in, then, is the pattern of satisfied responses among various subgroups of the beneficiary population.

Table 6 shows the percent satisfied in the Medicare aged and disabled populations, stratified by a series of personal characteristics. Each percentage is compared to the column mean by its standardized difference, i.e., the difference between the subgroup measure of satisfaction and the population mean, adjusted statistically with the standard errors of each measure. This adjustment takes into account the magnitude and sample size of each measure, and allows comparisons to be made across the table. If the standardized difference exceeds plus or minus 2, the difference is estimated to be statistically significant with a probability of .05 (indicated by asterisks in the table).

Table 6

Percent of Medicare Beneficiaries Satisfied With Their Usual Source of Medical Care, by Selected Characteristics: MCBS Round 7

Characteristic	Aged				Disabled
	Technical		Interpersonal		Technical		Interpersonal
	Percent	Standardized Difference	Percent	Standardized Difference	Percent	Standardized Difference	Percent	Standardized Difference
Total	91.4	—	85.6	—	87.8	—	81.5	—
Age
Under 45 Years	—	—	—	—	83.3	*-2.47	75.3	*-2.74
45-64 Years	—	—	—	—	90.1	1.76	84.6	1.84
65-69 Years	90.5	-1.08	86.0	0.41	—	—	—	—
70-74 Years	91.5	0.14	86.1	0.45	—	—	—	—
75-79 Years	91.7	0.37	84.7	-0.86	—	—	—	—
80-84 Years	92.2	0.99	85.4	-0.19	—	—	—	—
85 Years or Over	91.0	-0.41	85.2	-0.33	—	—	—	—
Education Highest Level
Grade School	92.5	1.40	83.6	-1.69	89.8	1.01	81.6	0.04
Grade School Graduate	91.9	0.51	84.0	-1.05	88.8	0.29	77.2	-0.86
High School	91.5	0.11	85.6	0.00	89.3	0.82	82.6	0.45
High School Graduate	90.9	-0.67	85.8	0.24	87.0	-0.46	82.7	0.61
College	91.0	-0.50	87.0	1.53	85.9	-0.84	80.0	-0.56
Race/Ethnicity
Hispanic	94.0	*2.50	83.2	-1.39	84.6	-0.99	74.9	-1.15
Black/African-American	93.2	1.59	87.7	1.57	89.9	1.13	82.7	0.63
White	91.0	-0.71	85.7	0.13	87.9	0.08	82.2	0.41
Other	91.4	0.00	80.8	-1.32	83.5	-0.63	79.4	-0.28
Perceived Health Status
Excellent	91.6	0.25	88.5	*2.62	92.5	1.46	83.6	0.52
Very Good	91.7	0.41	88.1	*2.73	88.6	0.32	81.8	0.10
Good	92.0	0.80	85.5	-0.11	89.4	0.94	82.4	0.38
Fair	89.9	-1.66	81.2	*-3.42	87.3	-0.30	81.2	-0.13
Poor	90.7	-0.53	80.6	*-2.98	85.5	-1.10	80.5	-0.48
Functional Status
No ADLs or IADLs	91.6	0.38	86.5	1.18	87.8	0.00	82.0	0.27
IADL Only	91.8	0.28	86.4	0.40	88.6	0.22	81.7	0.05
1-2 ADLs	89.4	-1.81	81.1	*-2.98	88.3	0.26	80.6	-0.36
3-4 ADLs	90.6	-0.54	81.2	*-2.27	88.6	0.27	77.0	-1.01
5 or More ADLs	92.5	0.61	86.0	0.20	83.5	-1.04	87.5	1.35
Usual Source of Care
Doctor's Office	92.6	*2.20	86.6	1.29	89.6	1.39	83.9	1.40
Doctor's Clinic	89.3	-1.60	83.0	-1.76	87.4	-0.16	83.4	0.55
Health Maintenance Organization	86.9	*-2.98	84.8	-0.44	69.1	*-2.28	62.8	*-2.02
Hospital Outpatient or Emergency Department	84.9	*-2.82	79.4	*-2.24	86.3	-0.54	77.0	-1.28
Department of Veterans Affairs Clinic	80.9	*-2.31	78.7	-1.88	82.5	-1.25	76.3	-0.97
Neighborhood/Family Health Center	91.6	0.07	75.0	*-2.32	83.0	-0.85	77.2	-0.65
Other Clinic	84.7	*-2.11	80.8	-1.26	83.8	-0.84	69.5	*-2.03
Insurance Coverage
Medicare and Private	91.4	0.00	86.2	0.79	89.4	1.09	86.1	2.28
Medicare and Medicaid	92.1	0.68	81.4	*-2.64	86.3	-0.99	79.0	-1.21
Medicare Only	89.8	-1.07	84.2	-0.92	87.6	-0.09	77.7	-1.35
Medicare and Public	93.9	1.09	85.4	-0.05	89.6	0.47	85.1	0.74
Medicare Group Health Membership
No Membership	91.8	0.72	85.8	0.27	88.2	0.33	81.9	0.25
At Least 1 Month	87.0	*-3.39	83.5	-1.28	77.3	-1.66	69.6	-1.51
Income
$5,000 or Less	93.7	1.87	86.5	0.52	88.3	0.19	81.7	0.06
$5,001-$10,000	90.2	-1.43	82.8	*-2.53	87.0	-0.54	78.8	-1.39
$10,001-$15,000	92.1	0.81	85.2	-0.35	89.2	0.70	83.3	0.64
$15,001-$20,000	91.6	0.23	86.2	0.51	87.3	-0.17	77.5	-0.94
$20,001-$25,000	89.9	-1.26	84.6	-0.67	87.3	-0.11	84.4	0.66
$25,001-$30,000	89.4	-1.37	86.9	0.80	88.4	0.17	88.2	1.83
$30,001-$35,000	93.1	1.14	87.4	0.98	90.1	0.64	85.3	0.77
$35,001-$40,000	94.1	1.47	92.9	*3.84	87.5	-0.05	80.6	-0.14
$40,001-$45,000	89.8	-0.67	85.2	-0.15	96.1	*2.05	96.1	*3.55
$45,001-$50,000	90.9	-0.20	87.4	0.72	—	—	—	—
$50,001 $or More	92.5	0.80	88.2	1.38	89.8	0.34	91.1	1.76

p < .05.

Sample excludes community residents with no usual source of care and non-community residents.

NOTES: MCBS is Medicare Current Beneficiary Survey. ADLs is activities of daily living. IADLs is instrumental activities of daily living. Tables including standard errors available upon request from author.

SOURCE: Health Care Financing Administration: Medicare Current Beneficiary Survey Round 7, September 1-December 31, 1993.

The first finding from Table 6 is that the overall proportion of people satisfied with their usual source of medical care is quite high. In most of the groups, satisfaction was between 80-90 percent. This is consistent with the findings from the other measures of satisfaction previously discussed. The disabled are less satisfied than the aged, in total and in almost every subclassification.

Other than the gap between aged and disabled, there is very little variation in satisfaction, as we have measured it, among the subgroups of the population. Rarely does the proportion satisfied in any of the groups go below 80 percent. What we are left to look for in Table 6 are small but systematic variations in satisfaction that may lead to further hypotheses.

The aged show no discernible pattern of variation by age group. The older disabled (45-64 years of age), however, are significantly more satisfied than the group under 45 years of age on both technical and interpersonal scales.

The disabled show a small but consistent tendency for the less educated to be more satisfied with their care than those with more schooling. There is a contrary tendency among the aged; the more educated are likely to be more satisfied with the interpersonal aspects of their doctor's care.

Race/Ethnicity

Hispanic aged persons are more satisfied than average with their doctors' technical performance, but less so with the doctor/patient interaction. Otherwise, satisfaction scores seem uniformly high, with African-Americans' scores exceeding those of whites by a small amount.

In general, the better your health, the more likely you are to be satisfied with your doctor's performance. This is so for the disabled and the aged, although individual scores are significantly different from the mean only for interpersonal satisfaction among the aged.

There is little relationship between level of impairment and patient satisfaction. The aged in the middle of the impairment scale (1-4 ADLs) may be less satisfied than those at either end; their scores for interpersonal satisfaction are significantly below the average.

The site of care is a strong factor in patient satisfaction. The highest degree of satisfaction is consistently with care in a doctor's office or group practice. HMO care is scored low on technical satisfaction for the aged and on both scales for the disabled. Aged beneficiaries rate neighborhood and family health centers high in technical satisfaction, but low in interpersonal satisfaction. Hospital outpatient or emergency clinics are rated low by the aged in both technical and interpersonal satisfaction, but low-to-average by the disabled. Veterans' clinics are rated lowest of all sources by the aged in technical quality (-2.3) and almost as low in interpersonal satisfaction (-1.9).

People with public or private supplementary insurance seem satisfied in both groups on both scales. Medicaid recipients are somewhat anomalous: they rate their doctors low on interpersonal satisfaction, but close to the mean with regard to technical skills. Medicare-only beneficiaries are low in satisfaction across the board, but individual scores are not statistically significant.

Group Health Plan Participation

There is clear indication that members of group health plans under Medicare have less confidence in their doctors' technical skills and interpersonal performance than those who use traditional FFS providers, especially among the disabled. These findings are consistent with the results of another large HCFA-sponsored study which evaluated the impact of Medicare enrollment in risk-contract HMOs (Clement et al., 1992). The evaluation, conducted by the Medical College of Virginia, found that the general level of satisfaction was high (90 percent or more), but that HMO enrollees were less highly satisfied (percent rating excellent) than FFS patients to a statistically significant degree. The only area in which HMO satisfaction exceeded FFS was out-of-pocket costs incurred for health care. Similar differences between HMO and FFS satisfaction were found in the Medical Outcomes study (Rubin et al., 1993).

There is no clear relationship between income and satisfaction in either group on either scale.

Discussion

This article is primarily descriptive and exploratory in nature. In general, people who are covered by Medicare seem to be very satisfied with the care they receive through the program. The various measures of satisfaction included in the MCBS are consistent in their measurements, a factor giving us confidence that a real phenomenon is being measured (convergent validity).

The finding of a high overall level of satisfaction is consistent with the literature on health care satisfaction. Not only is there high satisfaction with care, but there are no beneficiary groups we examined that are predominantly dissatisfied.

There are some variations: people with poorer health status, those covered by Medicaid or without supplementary insurance, those with HMOs or clinics as their usual source of care, and the disabled population in general appear by these measures to have lower levels of satisfaction. We can hypothesize about the reasons for these differences. A next step would be to hold more variables constant to further explore the regularities which we have begun to describe here.

The ultimate issue is whether the patient, as an informed consumer, can make those decisions that will maximize his or her satisfaction with care. This is an issue which analysis of MCBS data over time may begin to address.