People use health care services for many reasons: to cure illnesses and health conditions, to mend
breaks and tears, to prevent or delay future health care problems, to reduce pain and increase
quality of life, and sometimes merely to obtain information about their health status and prognosis.
Health care utilization can be appropriate or inappropriate, of high or low quality, expensive or
inexpensive. The study of trends in health care utilization provides important information on these
phenomena and may spotlight areas that may warrant future indepth studies because of potential
disparities in access to, or quality of, care. Trends in utilization may also be used as the basis for
projecting future health care needs, to forecast future health care expenditures, or as the basis for
projecting increased personnel training or supply initiatives.
The health care delivery system of today has undergone tremendous change, even over the relatively
short period of the past decade. New and emerging technologies, including drugs, devices, proce-
dures, tests, and imaging machinery, have changed patterns of care and sites where care is pro-
vided (1,2). The growth in ambulatory surgery has been influenced by improvements in anesthesia
and analgesia and by the development of noninvasive or minimally invasive techniques. Procedures
that formerly required a few weeks of convalescence now require only a few days. New drugs can
cure or lengthen the course of disease, although often at increased cost or increased utilization of
medical practitioners needed to prescribe and monitor the effects of the medications.
Over the past decade, both public and private organizations have made great strides in identifying
causes of disease and disability, discovering treatments and cures, and working with practitioners to
educate the public about how to reduce the incidence and prevalence of major diseases and the
functional limitations and discomfort they may cause. Clinical practice guidelines have been created
and disseminated to influence providers to follow recommended practices. Public education cam-
paigns urge consumers to comply with behavioral recommendations (e.g., exercise and lose weight)
and treatment regimens (e.g., take your medications) that may help to prevent or control diseases
and their consequences.
Health care utilization also has evolved as the population’s need for care has changed over time.
Some factors that influence need include aging, sociodemographic population shifts, and changes in
the prevalence and incidence of different diseases. As the prevalence of chronic conditions increases,
for example, residential and community-based health-related services have emerged that are de-
signed to minimize loss of function and to keep people out of institutional settings.
The growth of managed care and payment mechanisms employed by insurers and other payers in
an attempt to control the rate of health care spending has also had a major impact on health care
utilization. Efforts by employers to increase managed care enrollment, as well as major Medicare
and Medicaid cost containment efforts such as the Prospective Payment System for hospitals and the
Resource Based Relative Value Scale for physician payment, created incentives to shift sites where
services are provided (3,4). They also created incentives to provide services differently; for example,
the increase in capitated payment and use of gatekeepers has been associated with a changing mix
of primary care and specialty care (see “Visits to Primary Care and Specialty Physicians”) (5). Nu-
merous other factors also influence the type and amount of health care utilization that is provided in
the United States (see “Forces that Affect Overall Health Care Utilization”) (6,7).
The Centers for Disease Control and Prevention, National Center for Health Statistics (NCHS), Division of Health Care Statistics is charged with conducting surveys of health care providers and facilities. These surveys track the number of encounters these entities provide and describe characteristics of
Health Care in America: Trends in Utilization
those who seek care, the content of the encounters, and characteristics of providers. It accomplishes
this mission in part by fielding a family of surveys that are collectively called the National Health
Care Survey (NHCS). The NHCS produces important information on hospitalizations and surgeries,
ambulatory physician visits, and long-term care use in the United States. It can be used to compare
services received across different settings, to relate provider characteristics to patient utilization, to
compare utilization rates among subpopulations, and, in general, to assess how the health care
delivery system is being used and by whom.
Each NHCS component survey obtains information about the facilities that supply health care, the
services rendered, and the characteristics of the patients served. Each survey is based on a multi-
stage sampling design that includes health care facilities or providers and patient records. Data
collected directly from the establishments and/or their records rather than from the patients, identify
health care events—such as hospitalizations, surgeries, and long-term stays—and offer the most
accurate and detailed data on diagnosis and treatment and institution characteristics. These data are
used by policymakers, planners, researchers, and others in the health community for a variety of
purposes, including monitoring changes in the use of health care resources, monitoring specific
diseases, and examining the impact of new medical technologies (8)