Alberta Health Care Utilization Study (1968 and 1970): SOME PRELIMINARY DATA ON THE 1968 PRE-MEDICARE PHASE

Alberta Health Care Utilization Study (1968 and 1970): SOME PRELIMINARY DATA ON THE1968 PRE-MEDICARE PHASEAuthor(s): Stanley GreenhillSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 62, No.1 (January/February 1971), pp. 17-22Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41984926 .

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Alberta Health Care Utilization Study

(1968 and 1970)1 SOME PRELIMINARY DATA ON THE 1968 PRE-MEDICARE PHASE

Stanley Greenhill,2 m.d., d.p.h., c.r.c.p.

Data obtained from the pre - Medicare phase of the Alberta Pre and Post Medicare Health Care Utilization Patterns project are presented. These data indicate that utilization of doctor and doctor-related services is higher in the medically insured than in the uninsured , and that insurance status rather than income level determines utilization.

The absence of up-to-date Canadian morbidity data is discussed. A plea is made for publication of morbidity data derived from doctors' submissions to health care commis- sions and reactivation of a modified Canadi- an Sickness Survey with a built-in updating capability.

TT WOULD appear that as the health of a A nation improves so does its concern with illness. This paradox becomes intelligible when it is realized that a nation's attitude to health is the result of many factors - social, economic, cultural, and political - to mention but a few. Instead of being born into sin, man it appears is now born into sickness. A nation's health care delivery system, or non- system, is a reflection of the interplay of these many factors.

A nation seems to develop a state of morbid introspection when a certain degree of technical competence and economic productivity has been achieved. The resulting afflu- ence and leisure do not produce masses of happy and healthy citizens but rather masses of morbidity and illness.

The demand for health care services and facilities appears to be insatiable. This syndrome of improved socio-economic status, im- proving health indices with increasing health

1. Based on a paper presented at the 1st International Congress on Group Medicine, Winnipeg, April 27-30, 1970. 2. Professor and Chairm?n, Department of Community Medicine, University of Alberta, Edmonton, Alberta.

care and costs is doubtless a manifestation of some type of pathology in the body politic.

This syndrome has many of the character- istics of a neoplastic growth. If left un- checked the disease process could lead to the death of the host - the body politic. Though the actual processes by which this pathology is produced are unknown, the causative agents can be identified. They are the con- sumers of health care services, and their rate of consumption is increasing by four to five per cent annually in Canada.

An ideal opportunity to study this syndrome presented itself in Alberta in 1968, a year before the provincial implementation (the Alberta Health Care Insurance Act) of the federal Medical Care Act in July 1969. The effect of the Alberta Health Care Insur- ance Act on patterns of health care utilization is now being studied, and will be completed by July 1971. It is hoped that through studying the patterns of health care utilization by Albertans before and after the intro- duction of Medicare a greater understanding will result of the predisposing factors that eventually result in use being made of health services.

The Populations Sampled Two contrasting medical catchment areas

were selected - an urban center, the city of Edmonton, and a rural region, the Red Deer area, for the questionnaire survey. The over- all completion rate was 90 per cent. A total of 1,199 households in the two catchment areas were surveyed. The households were made up of 2,308 adults, and 1,071 children representing the youngest and oldest child in each household.

Selection of these regions permitted analysis of two kinds of catchment areas and four types of populations - metropolitan, small city, small town, and rural.

17



Precautions were taken in selecting the samples to ensure an adequate number of cases for reliable generalizations about health service utilization by insured and uninsured families from the four population types.

The mechanics of sampling were greatly facilitated by availability of voter enumera- tion lists. All persons aged 19 and over in Al- berta are enumerated by household regard- less of voter eligibility. It was a relatively simple matter to select a systematic random sample from those voters' lists. Not only did these lists simplify and reduce the cost of sample selection but they permitted the draw- ing of a systematic random sample rather than a cluster sample. The advantage of a systematic sample over a cluster sample is of course the increased certainty of representa- tiveness and a lessening of sampling error.

The Questionnaire The "Alberta Health Care Study" ques-

tionnaire was modeled after that used in the "International Comparisons of Medical Care Utilization - A Feasibility Study" (1).

The modifications and additions to that questionnaire were in items dealing with medical insurance status, and health related attitudes." A preliminary communication on the analysis of these health related attitude questions was presented to the Royal College of Physicians and Surgeons (Canada) annual meeting in January 1970 (2).

ing tabulations based on the pre-Medicare phase of the study are nevertheless presented. The Red Deer city population sample has been excluded from the tables because of the disproportionately small number of uninsured - 54 uninsured compared with 348 insured respondents.

Some Demographic Data Table I presents a breakdown of the sur-

vey sample according to sex and insured status. Despite sampling methods designed to obtain adequate representation of the medically uninsured, they formed a minority.

Table I: Sex Distribution of the Insured and Uninsured in the: Urban and Rural Sample

Areas as A Percentage of Those Responding No. Male Female

Insured 550 46.5 53.5 Urban

Uninsured 277 46.9 53.1 Insured 742 50.1 49.9

Rural Uninsured 337 57.6 42.4

The relatively large number of urban respondents in the 18 to 24 age group who are uninsured is probably a reflection of their single status, not having coverage through their parents' medical insurance, and their as- sumption that illness occurring to themselves is a remote possibility. (Table II).

Table II: Age Distribution of the Insured and Uninsured in the Urban and Rural Sample Areas As a Percentage of Those Responding (1968)

18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 years No. Years* Years Years Years Years and over

Insured 547 18.8 23.0 20.8 14.5 10.9 11.9 Urban

Uninsured 273 28.2 19.8 18.3 17.6 8.1 8.1

Insured 737 11.2 14.6 17.6 22.2 17.8 16.6 Rural

Uninsured 335 8.7 15.0 19.7 26.5 16.2 14.1 ♦Includes 7 persons under 18 who were married.

Some Preliminary Analysis of the Data (Pre- Medicare, 1968)

At the present time (spring/ summer, 1970) the field work of post-Medicare phase of the "Alberta Health Care Study" is actively under way. It is therefore not yet possible to provide findings related to the prime objec- tive of the study - differences in utilization patterns pre- and post-Medicare. The follow-

Table III indicates that those respondents with the least formal education were the least likely to have medical insurance.

The greater number of uninsured in the low income brackets as shown in Table IV is doubtless due to several unidentified varia- bles - sex, education, type of job, or age.

Table V demonstrates that farmers do not carry medical insurance nearly to the same

18 Canadian Journal of Public Health Vol. 62



Table III: Formal Schooling Distribution of Insured and Uninsured in they Urban and Rural Sample Areas As a Percentage of Those Responding

Junior Some Completed Univer- None to High High High Some sity

No. Elementary School School School University Degree Insured 543 16.8 16.0 25.0 27.4 9.0 5.7

Urban Uninsured 275 21.8 17.1 26.2 20.0 11.6 3.3

Insured 736 12.9 32.1 28.8 16.6 6.1 3.5 Rural

Uninsured 333 14.7 44.7 26.4 10.8 2.7 0.6

Table IV: Family Income Distribution of Insured and Uninsured in The Urban and Rural Sample Areas As a Percentage of Those Responding (1968)

Indiv. Under $1,000- $2,000- $3,000- $4,000- $5,000- $6,000- $7,500- $10,000 No. $1,000 2,000 3,000 4,000 5,000 6,000 7,500 10,000 and over Urban Insured 499 1.6 3.8 7.0 8.0 10.8 15.8 18.4 19.4 15.0 Urban Uninsured 242 1.2 8.5 3.7 14.6 23.2 12.2 12.2 17.1 7.3 Rural Insured 659 4.4 13.2 12.0 12.9 10.2 10.0 7.3 14.3 15.8 Rural Uninsured 305 11.1 8.9 9.8 18.4 8.9 8.5 7.9 9.5 17.0

Table V: Occupational Distribution of Insured and Uninsured in the Urban and Rural Sample Areas as a Percentage of Those Responding (1968)

Branch Other Farm Owners Man., Skilled Workers

Higher Lesser or Off. Clerical Skilled Workers, Truck and Exec., Exec., Man. of Man., and Const. Police- Semi- and other Prof., Prof., Small Techn. Sales Trades- men skilled Bus Unskilled

No. Prop. Farmers Prop. Bus. Etc. Workers men etc. Workers Drivers Workers Urban Insured 314 4.1 1.3 10.3 3.5 7.3 23.2 7.3 7.3 16.3 4.8 14.6

Uninsured 158 3.8 4.4 6.9 4.4 4.5 20.3 16.5 3.2 15.8 8.9 11.4 Rural Insured 430 1.4 40.2 7.6 4.7 3.1 8.0 4.9 3.2 12.3 3.3 11.4

Uninsured 195 0.5 69.0 0.0 4.1 1.0 4.1 4.1 0.5 5.6 2.6 8.7

extent as other occupational groups. This difference will be studied in greater detail - whether it is a health related attitude, a reflection of rural non-sophistication, or a difference in economic values is still a matter for conjecture.

Utilization and Insurance Status The increased utilization of doctors' serv-

ices by females irrespective of their medical insurance status is apparent in Table VI.

Respondents who reported their health as poor varied significantly between the insured and uninsured as shown in Table VII.

The differences in incidence of perceived morbidity in all strata of the survey sample

Table VI: Utilization of Doctor Services According to Sex as Percentage

Time Since Last Visit Male Female To Doctor (All Ages) 0-1 Year 63.4 78.6 1-5 Years 26.5 17.9 + 5 Years 10.1 3.5

Male: N =1114 Female: N- 1164 seen in Table VII may be compared to doctor utilization by insurance status of respondents (Table VIII). In order to study this apparent direct relationship between utilization and insured status from a different angle, the responses to a question relating to vision are listed in Table IX.

January/ February 1971 Alberta Health Care Study 19



Table VII: Perceived Morbidity Indicators of Insured and Uninsured in the Urban and Rural

Sample Areas as a Percentage of Those Responding

Reported Health As Poor

No. Per cent Insured 548 7.5

Urban Uninsured 275 5.5

Insured 741 7.3 Rural

Uninsured 336 4.8

Table VIII: Doctor Consultation or Visit in Last Two Weeks by Insured and Uninsured in The

Urban and Rural Sample Areas as A Percentage of Those Responding

Yes, Has Seen A Doctor In Last Two Weeks

No. Per cent Urban Insured 550 18.5 Urban Uninsured 277 9.7 Rural Insured 742 17.3 Rural Uninsured 337 6.5

Table IX: Examinations for Vision Insured and Uninsured - Urban and Rural

Eyes Never Checked For Vision

No. Per cent

Urban Insured 542 12.4 Urban Uninsured 273 20.1 Rural Insured 738 12.9 Furai Uninsured 334 22.5

The uninsured in all three study areas have sought less care for their eyes than the insured.

The relationship of insured status to hospitalization is most marked in the rural areas (Table X). Perhaps this reflects the prevailing practice patterns in such regions. The relative lack of diagnostic facilities for ambulatory patients, and the distance between a respond- ent's place of residence and health facility may necessitate greater hospital utilization.

The urban insured do not demonstrate the same trend to hospitalization. There is little difference in rates of hospitalization between the insured and uninsured. Accessibility of ambulatory diagnostic facilities may contrib-

Table X: A Hospital Stay Within The Last 12 Months of Insured and Uninsured in The Urban and Rural Sample Areas as A Percentage of

Those Responding Yes, Was In Hospital In Last 12 Months

No. Per cent

Urban Insured 550 14.2 Urban Uninsured 277 13.4 Rural Insured 740 19.7 Rural Uninsured 337 11.0

Table XI: The Use* of Prescribed Medication by Insured and Uninsured as A Percentage of

Those Responding Used Prescribed

Medication No. Per Cent

Urban Insured 547 31.4 Urban Uninsured 276 15.9 Rural Insured 741 32.8 Rural Uninsured 336 17.3

N = Sample Size *In the two weeks prior to interview.

ute to this difference; or unavailability of hospital beds in the larger centers. Cost of hospitalization was not a deterrent factor as in 1968 pre-paid hospitalization already exist- ed in Alberta.

It has already been demonstrated in pre- vious tables that the medically insured use both doctors and hospitals more. Table XI indicates that the medically insured also use more prescribed medications.

Income, Doctor Utilization and Insurance Tables XII and XIII suggest that the utili-

zation rates of the medically insured are little affected by income or by whether the insured live in town or country. The medically uninsured utilization rate likewise seems un- related to income, though they make less use of doctors' services than the insured. The medical insurance status of respondents rather than their income would seem to be the factor leading to higher utilization rates.

Income, Dental Utilization and Insurance Tables XIV and XV on utilization of den-

tists make an interesting comparison with those previously shown for doctors. Dental utilization appears directly related to and in- creases with income. No dental insurance exists in Alberta.




Table XII: Doctor Utilization Urban (1968) Time Since Last Visit by Income and Insurance Status Number Of 0-1 Year 1-5 Years +5 Years

Income ($) Insured Uninsured Insured Uninsured Insured Uninsured Insured Uninsured

0-3,000 122 53 85.3% 69.9% 13.1% 20.7% 1.6% 9.4% 3,001-5,000 147 71 78.2% 69.0% 18.4% 22.6% 3.4% 8.4% 5,001-7,500 275 95 73.9% 65.3% 22.9% 28.4% 3.2% 6.3%

+7,500 235 67 78.3% 55.2% 17.9% 38.8% 3.8% 6.0%

Table XIII: Doctor Utilization Rural (1968) Time Since Last Visit by Income and Insurance Status Number Of O-l Year 1-5 Years +5 Years

Income ($) Insured Uninsured Insured Uninsured Insured Uninsured Insured Uninsured

0-3,000 187 97 79.7% 50.5% 16.1% 23.7% 4.3% 25.8% 3,001-5,000 154 79 77.3% 48.1% 19.5% 38.0% 3.2% 13.9% 5,001-7,500 112 52 67.8% 63.4% 26.0% 26.9% 6.2% 9.7%

+7,500 189 87 78.3% 46.0% 19.6% 32.2% 2.1% 21.8%

Table XIV: Dentist Utilization Urban (1968) Time Since Last Visit by Income and Insurance Status Number Of 0-1 Year +1 Year

Income ($) Insured Uninsured Insured Uninsured Insured Uninsured

0-3,000 122 55 25.4% 29.1% 27.6% 70.9% 3,001-5,000 149 80 46.2% 26.2% 63.8% 73.8% 5,001-7,500 275 95 44.7% 66.8% 55.3% 63.2%

+7,500 241 66 53.1% 42.4% 46.9% 57.6%

Table XV: Dentist Utilization Rural (1968) Time Since Last Visit by Income and Insurance Status Number Of 0-1 Year +1 Year

Income ($) Insured Uninsured Insured Uninsured Insured Uninsured

0-3,000 189 97 25.4% 14.4% 74.6% 85.6% 3,001-5,000 155 80 24.6% 21.0% 77.4% 73.8% 5,001-7,500 112 52 35.8% 28.9% 64.2% 71.1%

+ 7,500 192 87 40.6% 32.2% 59.4% 67.8%

General Comments It is apparent from this paper that the "Al-

berta Health Care Study" has taken into ac- count a variety of factors contributing to health care utilization patterns, from the usual heads and beds count, to such items as medical insurance status, time and distance from health facilities and personnel, health related attitudes, income, and perceived morbidity - to mention but a few. One obvious data lack is the difficulty if not impossibility, of relating perceived morbidity with real morbidity as it exists in the population at large.

This lack of up-to-date Canadian morbidity data is a serious one. "The principal use of morbidity statistics is in the description and investigation of patterns of occurrence of illness and of the use of medical care, to the end that available resources may be most effectively directed towards maintenance and promotion of public health" (2). Studies that provide health care data are logical precur- sors to formulation of any new health policies and implementation of new health pro- grams.

In spite of our reverence for technology, and in spite of our present cult of computer

January/February 1971 Alberta Health Care Study 21



worship, no mechanism in Canada has yet been established for the regular acquisition and constant up-dating of morbidity data in a representative sample of our population. It is sad to contemplate the millions of information bits being accumulated from hospital rec- ords and doctors' claim cards that never will appear as meaningful print-outs. Yet these data could provide our health planners with the types of information on which they could make rational and logical projections of the country's health needs, and our educators of health professionals with realistic and appro- priate educational objectives.

The mention of the need for morbidity data is not irrelevant. The absence of readily available morbidity data to those working in the health care field is deplored. The lack of availability of such data to those responsible for health policies and/ or health planning must result in their decision-making being a somewhat haphazard procedure. This lack should be a matter of personal and national concern for decisions made in the health care field inevitably involve the expenditure of millions of dollars of public funds.

Conclusions A preliminary tabulation of some of the

data obtained during the 1968 pre-Medicare phase of the "Alberta Health Care Study" based on a field questionnaire survey of 3,- 379 Albertans has been presented.

Four general observations rather than conclusions can be made from the data presented. (1) Although perceived morbidity was higher in the medically insured than in the uninsured, the differences in utilization of doctors and doctor-related services between the two groups were proportionally much greater. (2) Utilization of doctor services was independent of income. (3) Utilization of dental services was dependent on income. (4) Universal health coverage will result in greater utilization of Canada's health manpower.

ACKNOWLEDGEMENTS The author wishes to express thanks to D.

Haythorne, M.A., Project Co-ordinator, and R. Taylor, B.A., Research Assistant, for their as- sistance in the preparation of this paper.

These health utilization studies have been funded through Project Number 608-7-106, De- partment of National Health and Welfare.

REFERENCES 1. White, K. L. and Murnaghan, J. H.: "In-

ternational comparisons of medical care utilization": Public Health Service Publication No. 1,000, Series 2, No. 33. U.S. Department of Health, Education, and Welfare, Washing- ton, D.C. June 1969.

2. Royal College of Physicians and Surgeons:

"The consumer - the silent majority". Health care symposium held at annual meeting, Montreal, January 1970.

3. World Health Organization: "Morbidity Sta- tistics". Technical Report Series, No. 389, Geneva 1968.




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Alberta Health Care Utilization Study (1968 and 1970): SOME PRELIMINARY DATA ON THE 1968 PRE-MEDICARE PHASE