{ "study": { "slug": "medicare-utilization-penetration-2026", "title": "What Medicare actually uses: service penetration and caseload, 2025", "standfirst": "Across 24 Medicare service categories, only one — preventive health — reaches more than half of fee-for-service beneficiaries (53.6%); the median reaches under 6%. The load is uneven: 2,303 labs serve 15.6 million beneficiaries, 6,754 apiece, while physical therapists average 40. CMS publishes this utilization map as the demand-side mirror of market saturation.", "desk": "access", "article_type": "Original Research", "published": "2026-06-16", "issue": 81, "doi": "10.5072/fonteum/medicare-utilization-penetration-2026", "url": "https://fonteum.com/research/medicare-utilization-penetration-2026", "methodology_version": "market-saturation/v1" }, "data_as_of": "2026-06-16", "datasets": [ { "slug": "cms-provider-data-catalog", "name": "CMS Provider Data Catalog", "publisher": "CMS — Provider Data Catalog", "upstream_url": null } ], "key_findings": [ { "number": "53.6%", "finding": "of Medicare's fee-for-service population uses preventive health services — 21.2 million of 39.6 million beneficiaries — the only one of 24 service categories that reaches more than half. The median category reaches under 6% of beneficiaries", "dataset": "cms-provider-data-catalog" }, { "number": "6,754", "finding": "beneficiaries served per provider at independent clinical laboratories — 2,303 labs reach 15.6 million people, 39.3% of all FFS beneficiaries. Diagnostic-testing facilities carry 4,312 each; physical therapists average 40 — a 184-fold caseload spread across the same program", "dataset": "cms-provider-data-catalog" }, { "number": "40.7%", "finding": "of the 1.49 million beneficiaries who use a Federally Qualified Health Center are dual-eligible for Medicare and Medicaid — the highest dual share of any service and a marker of the low-income population. Chiropractic is the lowest at 4.4%", "dataset": "cms-provider-data-catalog" }, { "number": "24.3 points", "finding": "separate the highest state from the lowest in preventive-care use — Delaware reaches 67.6% of its beneficiaries, Maine 43.3%. Even Medicare's most-used service reaches barely four in ten beneficiaries in some states", "dataset": "cms-provider-data-catalog" }, { "number": "68,068", "finding": "point-in-time records make up the latest annual period (2025), 24 service categories across nation, state, and county; 24 are NATION + TERRITORIES rollups. This is the demand-side (Utilization) half of the same CMS file behind market saturation — every figure is an aggregate count or share, and no provider is named", "dataset": "cms-provider-data-catalog" } ], "faqs": [ { "q": "What does Medicare 'utilization' mean in this data?", "a": "Utilization here is the share of fee-for-service beneficiaries who actually used a given service in the year — providers per market is the saturation measure, but the users column counts the people on the receiving end. Divide the number of users by the number of FFS beneficiaries and you get a penetration rate: what fraction of Medicare's population a service reaches. CMS publishes both halves in the same Market Saturation & Utilization file." }, { "q": "Which Medicare service reaches the most beneficiaries?", "a": "Preventive health services. In 2025 it reached 21.2 million of Medicare's 39.6 million fee-for-service beneficiaries — 53.6%, the only one of 24 service categories that reaches more than half. Independent diagnostic-testing facilities (42.3%) and clinical laboratories (39.3%) follow. Most categories reach far fewer people: the median service touches under 6% of beneficiaries, and seventeen of the twenty-four reach under 10%." }, { "q": "Why do clinical labs serve thousands of beneficiaries each while therapists serve dozens?", "a": "Because they are built differently. Independent clinical laboratories and diagnostic-testing facilities are a small number of high-throughput facilities — 2,303 labs and 3,883 testing facilities nationally — that process specimens and orders for a huge share of the program, 6,754 and 4,312 beneficiaries each. Office-based clinical services like physical therapy, chiropractic, and psychotherapy are delivered face-to-face by tens of thousands of practitioners, so each one carries 40 to 60 beneficiaries. The 184-fold gap is a structural feature of how each service is organized, not a quality difference." }, { "q": "Does high or low utilization mean a service is good or bad?", "a": "Neither. Utilization is a reach measure. A high share means a service touches many beneficiaries; a low share can mean it is specialized (dialysis, long-term care hospitals), discretionary (chiropractic), or hard to access. It says nothing about the quality of the care, whether the volume is appropriate, or how much was billed. This study reports geography- and service-level shares only and names no provider." }, { "q": "What is the dual-eligible share, and why does it vary so much?", "a": "Dual-eligibles are beneficiaries covered by both Medicare and Medicaid — generally the lowest-income part of the Medicare population. The data reports, for each service, what share of its users are dual-eligible. That share is highest at Federally Qualified Health Centers (40.7%), dialysis (34.2%), and psychotherapy (26.0%) — services that disproportionately reach low-income beneficiaries — and lowest for chiropractic (4.4%) and physical therapy (7.9%). It is a map of who reaches which service, not a judgment about any of them." }, { "q": "Can I reproduce these figures?", "a": "Yes. Every number aggregates the public cms_market_saturation table — the CMS Market Saturation & Utilization State-County files, snapshot release 2025-12-01 — over its most recent annual period. The exact SQL for the national penetration ranking, the caseload spread, the dual-eligible mix, and the state-level preventive-care variation is published in the reproducibility block below." } ], "citation": { "apa": "Fonteum Research. (2026, June 16). What Medicare actually uses: service penetration and caseload, 2025. Fonteum Research, Issue 81. https://doi.org/10.5072/fonteum/medicare-utilization-penetration-2026", "url": "https://fonteum.com/research/medicare-utilization-penetration-2026" }, "reproducible_sql": "-- What Medicare actually USES — the demand-side (Utilization) half of the CMS\n-- Market Saturation & Utilization file. Fully reproducible query.\n--\n-- Question: of the 24 Medicare fee-for-service service categories CMS tracks,\n-- how much of the beneficiary population does each one actually reach\n-- (penetration), how many beneficiaries does each provider carry (caseload),\n-- and which services concentrate among low-income dual-eligible beneficiaries?\n-- The lead figure: preventive health services reaches 53.6% of FFS\n-- beneficiaries — the ONLY category above half — while the median category\n-- reaches under 6%. Utilization is a REACH measure: it says nothing about the\n-- quality of care, the volume billed, or any provider's conduct.\n--\n-- Source:\n-- public.cms_market_saturation — CMS \"Market Saturation & Utilization\n-- State-County\" public-use files, published via the CMS data catalog\n-- (data.cms.gov, Program Integrity > Market Saturation by Type of Service).\n-- 1,030,290 rows across 15 yearly reference periods (2020–2025), 24 service\n-- categories, three aggregation levels (NATION + TERRITORIES, STATE,\n-- COUNTY). Snapshot release 2025-12-01. Public, read-only.\n-- License: US-Government-Works (17 U.S.C. Sec. 105).\n-- methodology_version = 'market-saturation/v1'.\n--\n-- Period: this study reads only the MOST RECENT annual period, resolved as\n-- max(reference_period) rather than hard-coded, so figures advance when CMS\n-- publishes the next file. Latest = '2025-01-01 to 2025-12-31', 68,068 rows\n-- (24 NATION + TERRITORIES rollups, 1,219 STATE, 66,825 COUNTY).\n--\n-- Counting note: \"users\" counts DISTINCT beneficiaries who used a service in\n-- the period — not visits, claims, or dollars. Penetration = users / FFS\n-- beneficiaries. The data is aggregate by construction: no individual\n-- beneficiary or provider appears, and none is named in the study.\n\n-- ============================================================================\n-- (0) Universe reconciliation — the table and the latest period at a glance.\n-- ============================================================================\nSELECT\n count(*) AS total_rows,\n count(DISTINCT reference_period) AS periods,\n count(DISTINCT type_of_service) AS services,\n max(reference_period) AS latest_period,\n max(source_release_date) AS release\nFROM public.cms_market_saturation;\n-- total_rows 1,030,290 · periods 15 · services 24\n-- latest_period '2025-01-01 to 2025-12-31' · release 2025-12-01\n\nSELECT\n count(*) AS latest_period_rows,\n count(*) FILTER (WHERE aggregation_level ILIKE 'NATION%') AS nation_rows,\n count(*) FILTER (WHERE aggregation_level ILIKE 'STATE%') AS state_rows,\n count(*) FILTER (WHERE aggregation_level ILIKE 'COUNTY%') AS county_rows\nFROM public.cms_market_saturation\nWHERE reference_period = '2025-01-01 to 2025-12-31';\n-- latest_period_rows 68,068 · nation 24 · state 1,219 · county 66,825\n\n-- ============================================================================\n-- (1) HEADLINE: penetration by service (national). Share of FFS beneficiaries\n-- who actually USE each service. Only preventive health clears 50%; the\n-- median category reaches under 6%; 17 of 24 reach under 10%.\n-- ============================================================================\nSELECT\n type_of_service,\n number_of_providers AS providers,\n number_of_users AS beneficiaries_reached,\n number_of_ffs_beneficiaries AS ffs,\n round(100.0 * number_of_users\n / nullif(number_of_ffs_beneficiaries, 0), 1) AS pct_users_of_ffs\nFROM public.cms_market_saturation\nWHERE reference_period = '2025-01-01 to 2025-12-31'\n AND aggregation_level ILIKE 'NATION%'\nORDER BY number_of_users DESC;\n-- Preventive Health Services 225,876 21,248,672 39,609,673 53.6% <- only category > 50%\n-- Indep. Diagnostic Testing Facility A 3,883 16,742,549 39,608,339 42.3%\n-- Clinical Laboratory (Billing Indep.) 2,303 15,554,744 39,608,749 39.3%\n-- Ophthalmology 47,498 12,283,238 39,604,303 31.0%\n-- Pulmonology 180,428 9,326,391 39,602,413 23.6%\n-- Durable Medical Equipment 45,963 7,358,733 39,598,270 18.6%\n-- Podiatry Services 15,172 4,425,256 39,532,230 11.2%\n-- Physical & Occupational Therapy 95,124 3,839,619 39,522,162 9.7%\n-- Home Health 8,488 2,613,941 39,524,879 6.6%\n-- Psychotherapy 35,557 2,108,821 39,480,134 5.3%\n-- Skilled Nursing Facility 12,919 1,141,379 39,391,060 2.9%\n-- Hospice 5,024 915,164 39,475,379 2.3%\n-- Dialysis 6,409 235,402 38,046,460 0.6%\n-- (… 24 categories total; tail includes Endocrinology 0.7%, Neurology 1.2%,\n-- Cardiac Rehab 0.5%, Long-Term Care Hospitals 0.1%.)\n\n-- Distribution summary — confirms \"only one over 50%, median under 6%\".\nSELECT\n count(*) AS services,\n count(*) FILTER (WHERE percentage_users_of_ffs > 50) AS over_50pct,\n count(*) FILTER (WHERE percentage_users_of_ffs >= 10) AS at_least_10pct,\n count(*) FILTER (WHERE percentage_users_of_ffs < 10) AS under_10pct,\n round(percentile_cont(0.5) WITHIN GROUP\n (ORDER BY percentage_users_of_ffs)::numeric, 2) AS median_pct\nFROM public.cms_market_saturation\nWHERE reference_period = '2025-01-01 to 2025-12-31'\n AND aggregation_level ILIKE 'NATION%';\n-- services 24 · over_50pct 1 · at_least_10pct 7 · under_10pct 17 · median_pct 5.98\n\n-- ============================================================================\n-- (2) CASELOAD: average users per provider (national). A handful of facility-\n-- based services carry thousands of beneficiaries each; office-based\n-- services carry dozens. The spread runs 6,754 (labs) to 37 (dialysis),\n-- a factor of ~184.\n-- ============================================================================\nSELECT\n type_of_service,\n number_of_providers AS providers,\n number_of_users AS beneficiaries_reached,\n average_users_per_provider AS users_per_provider\nFROM public.cms_market_saturation\nWHERE reference_period = '2025-01-01 to 2025-12-31'\n AND aggregation_level ILIKE 'NATION%'\nORDER BY average_users_per_provider DESC;\n-- Clinical Laboratory 2,303 15,554,744 6,754\n-- Indep. Diagnostic Testing Facility A 3,883 16,742,549 4,312\n-- Ambulance (Emergency & Non-Emergency)8,504 3,752,418 441\n-- Home Health 8,488 2,613,941 308\n-- Ophthalmology 47,498 12,283,238 259\n-- Hospice 5,024 915,164 182\n-- Durable Medical Equipment 45,963 7,358,733 160\n-- Psychotherapy 35,557 2,108,821 59\n-- Pulmonology 180,428 9,326,391 52\n-- Chiropractic Services 25,597 1,329,758 52\n-- Physical & Occupational Therapy 95,124 3,839,619 40\n-- Dialysis 6,409 235,402 37 <- lowest\n-- max/min = 6,754 / 37 = 184x\n\n-- ============================================================================\n-- (3) DUAL-ELIGIBLE MIX: share of each service's users who are dual-eligible\n-- (Medicare + Medicaid), a marker of the low-income population. FQHCs top\n-- the list at 40.7%; chiropractic is lowest at 4.4%. Services with > 200k\n-- users shown so small-base ratios do not distort the ranking.\n-- ============================================================================\nSELECT\n type_of_service,\n number_of_users AS beneficiaries_reached,\n number_of_dual_eligible_users AS dual_users,\n percentage_dual_of_total_users AS dual_share_pct\nFROM public.cms_market_saturation\nWHERE reference_period = '2025-01-01 to 2025-12-31'\n AND aggregation_level ILIKE 'NATION%'\n AND number_of_users > 200000\nORDER BY percentage_dual_of_total_users DESC NULLS LAST;\n-- Federally Qualified Health Center 1,492,047 606,466 40.65% <- highest\n-- Dialysis 235,402 80,518 34.20%\n-- Psychotherapy 2,108,821 547,860 25.98%\n-- Telemedicine 1,375,348 347,465 25.26%\n-- Ambulance (Non-Emergency) 1,323,893 333,214 25.17%\n-- Skilled Nursing Facility 1,141,379 275,248 24.12%\n-- Home Health 2,613,941 484,617 18.54%\n-- Durable Medical Equipment 7,358,733 1,015,788 13.80%\n-- Preventive Health Services 21,248,672 2,300,831 10.83%\n-- Ophthalmology 12,283,238 1,094,170 8.91%\n-- Physical & Occupational Therapy 3,839,619 303,478 7.90%\n-- Chiropractic Services 1,329,758 58,405 4.39% <- lowest\n\n-- ============================================================================\n-- (4) GEOGRAPHIC VARIATION: preventive-care penetration by state (the single\n-- most-used service). Even it ranges from 67.6% (DE) to 43.3% (ME) —\n-- a 24.3-point gap around the national 53.6%. States with >= 100k FFS\n-- beneficiaries only, so small-state ratios do not distort the ranking.\n-- ============================================================================\nWITH s AS (\n SELECT\n state,\n percentage_users_of_ffs AS pen,\n number_of_users AS users,\n number_of_ffs_beneficiaries AS ffs\n FROM public.cms_market_saturation\n WHERE reference_period = '2025-01-01 to 2025-12-31'\n AND aggregation_level ILIKE 'STATE%'\n AND type_of_service = 'Preventive Health Services'\n AND number_of_ffs_beneficiaries > 100000\n)\n(SELECT 'HIGH' AS tag, state, pen, users, ffs FROM s ORDER BY pen DESC LIMIT 5)\nUNION ALL\n(SELECT 'LOW' AS tag, state, pen, users, ffs FROM s ORDER BY pen ASC LIMIT 5)\nORDER BY tag, pen DESC;\n-- HIGH DE 67.58 · SC 61.95 · MA 60.42 · MD 59.37 · NJ 59.32\n-- LOW HI 45.36 · ID 44.78 · AK 44.64 · OR 44.07 · ME 43.34\n-- national preventive-health penetration = 53.6%; gap of the displayed rounded\n-- state rates 67.6 - 43.3 = 24.3 points (raw 67.58 - 43.34 = 24.24)", "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)", "generated_by": "Fonteum — https://fonteum.com", "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included." }