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Summary: Implications of Geographic Adjustment for Access, Quality, and Efficiency of Care T he Medicare program provides health coverage for more than 47 million Americans, including 39 million people aged 65 and older and 8 million people with disabilities. Although Medicare is a national program, it adjusts fee-for-service payments to Medicare providers for geographic differences in the costs of providing care. Payments in high-cost areas are increased relative to the national average, and payments in low-cost areas are reduced. Medicare spending reached $525 billion a year in 2010, so there is considerable interest in ensuring that payments are accurate in different parts of the country. In July 2010, the Department of Health and Human Services (HHS) commissioned the Insti- tute of Medicine (IOM) to produce two reports on improving the accuracy of the data sources and methods used for making geographic adjustments to fee-for-service Medicare payments. The statement of task for the 2-year study was developed by the IOM and the Centers for Medicare & Medicaid Services (CMS) on behalf of the Secretary of HHS, using language that came directly from Section 1157 of the Affordable Health Care for America Act (HR 3962) (see Box S-1). The first report, Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy, was released in May 2011, with a second edition following in September 2011. That report focused on the accuracy of estimates of labor and other input costs in fee-for-service payments under Medicare Part A (hospitals) and Part B (physicians and other clinical practitioners). The report recognized that some costs are beyond providers' control and recommended continua- tion of the use of indexes to calculate geographic adjustments with several significant changes and justifications. These changes include the use of one set of payment areas and one source of wage and benefits data for hospitals and practitioners; expanding the range of occupations used in making the geographic adjustments for employee compensation; and developing a new empirical model for adjusting practitioner payment. The report concluded that its recommen- dations, if implemented, would substantially improve the accuracy of Medicare's geographic payment adjustments and render unnecessary the many exceptions and reclassifications that exist in the current payment system. 1
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2 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT BOX S-1 Statement of Task An ad hoc committee will conduct a comprehensive empirical study on the accuracy of the geographic adjustment factors established under Sections 1848(e) and 1886(d)(3)(E) of Title XVIII of the Social Security Act and used to ensure that Medicare payment fees and rates reflect differences in input costs across geographic areas. Specifically, the committee will · E valuate the accuracy of the adjustment factors. · Evaluate the methodology used to determine the adjustment factors. · Evaluate the measures used for the adjustment factors for timeliness and frequency of revisions, for sources of data and the degree to which such data are representative of costs, and for operational costs of providers who participate in Medicare. Within the context of the U.S. health care marketplace, the committee will also evaluate and consider · T he effect of the adjustment factors on the level and distribution of the health care workforce and resources, including Recruitment and retention, taking into account mobility between metropolitan and nonmetropolitan areas; Ability of hospitals and other facilities to maintain an adequate and skilled work- force; and Patient access to providers and needed medical technologies; · The effect of adjustment factors on population health and quality of care; and · The effect of the adjustment factors on the ability of providers to furnish efficient, high-value care. A first report will address the issues surrounding the adjustment factors themselves, and then a second report that evaluates the possible effects of the adjustment factors will follow. The reports, containing findings and recommendations, will be submitted to the Secretary of HHS and the Congress. The current report addresses the second phase of the IOM study of geographic adjustments in Medicare payment. The committee members deliberated at length about how to approach the statement of task for Phase II, which included both very specific and very expansive language about their responsibilities. The Phase I report had recommended that geographic adjustment should be used only to improve technical accuracy of Medicare payments and that policy objec- tives, such as equitable access to health care services in high- and low-cost areas, or influencing the distribution of the workforce in shortage areas, should be addressed through other means. Thus, in Phase II, the committee was tasked with determining how its recommendations about the accuracy of geographic adjustment would affect access and quality of health care and the supply and distribution of the health care workforce. With regard to access to care, the committee learned from the payment simulations that payments to physicians and other
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SUMMARY 3 practitioners in shortage areas, which are disproportionately populated by racial and ethnic minorities, would be adversely affected by the Phase I recommendations. Particularly because the committee's recommended approach to geographic adjustment appeared to place some providers in shortage areas at an added disadvantage, the committee included analysis of the potential impact of its recommendations on high-risk and vulnerable populations and on other public programs designed to address shortages, as part of its charge. Although not explicitly mentioned in the statement of task, the committee sought to develop recommendations to help strengthen access and improve efficiency, particularly for high-risk and vulnerable populations, in order to address the adverse impact of the proposed adjustment. With regard to quality of care and the workforce supply and distribution, the committee did not find evidence that its recommendations about accuracy of geographic adjustment would have a significant impact. Taken together, the Phase I and Phase II reports seek to increase the likelihood that the geographic adjustments to fee-for-service Medicare payment reflect reasonably accurate mea- sures of input price differences and are consistent with the long-term national policy goals of creating a payment system that rewards high-value and high-quality health care. IMPACT ANALYSIS: PHASE I RECOMMENDATIONS In Chapter 2, the committee reports the findings of a series of statistical simulations con- ducted to obtain the estimated impact of the changes recommended in the committee's Phase I report on payments to hospitals and clinical practitioners. In designing the simulations, the committee sought to identify vulnerable, medically underserved geographic areas that might experience a disproportionate impact if the Phase I recommendations were implemented. The committee used Health Professional Shortage Areas (HPSAs)1 as the generally accepted representation of underserved areas for comparing access, quality, and workforce supply across geographic areas. HPSAs are a recognized standard in workforce research in that they are the official national designation of shortage areas, and they are also being used for a new incentive payment program for primary care services and general surgery in underserved areas from 2011 to 2015, as described in Chapter 4. There are some recognized drawbacks to using HPSAs, including their degree of currency and accuracy as designated shortage areas compared with other nondesignated areas; the degree to which they accurately reflect access barriers given that patients travel outside HPSAs to seek health care; their high practitioner vacancy rates and varying appeal to practitioners as practice locations; and the fundamental differences in access problems between rural and urban HPSAs. Nevertheless, the committee viewed HPSAs as the generally accepted standard and an acceptable basis for its deliberations and simulations. For purposes of the simulations, the committee used the definition of geographically based HPSAs for primary care services, as adopted by CMS for purposes of implementing the primary care bonus payment program initiated under the Affordable Care Act.2 Health professionals eligible for primary care bonus payments include physicians in general internal medicine, family practice, pediatrics, and geriatrics, as well as nurse practitioners (NPs) and physician assistants 1 Health Professional Shortage Areas are an administrative designation by the Health Resources and Services Admin- istration that identify areas with a low or insufficient primary care workforce (http://bhpr.hrsa.gov/shortage). 2 See Overview, HPSA/PSA Bonuses, at https://www.cms.gov/hpsapsaphysicianbonuses.
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4 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT (when billed under a supervising physician). The committee's approach was consistent with the evidence that access to primary care and having a usual source for routine medical care are generally associated with better health status. Key Findings from Hospital Payment Simulations 1.As a result of moving to a more technically accurate wage index, the change in payments would be between 5 and +5 percent for discharges in 88 percent of hospitals. 2.The most substantial differences in payments under the index as recommended by the committee as compared to payments under current CMS policy are the result of eliminating policy adjustments, such as the various exceptions, market reclassifications, and floors, rather than the result of technical corrections to improve accuracy. a. The largest negative effect on payments in metropolitan areas is due to the elimination of state rural floors for metropolitan areas in states where the index for the rural area is higher than an index for a metropolitan area. For the majority of these areas, the committee's revised index for metropolitan areas is lower than the index under the current system with the rural floor. b. Commuter-based smoothing adjustments have a modest effect on the hospital wage index for the great majority of counties (99 percent of the hospital wage indexes after smoothing are between 0.99 and 1.04), but smoothing serves to partially offset the effects of eliminating reclassifications. 3.A hospital wage index based on Bureau of Labor Statistics (BLS) data yields generally higher relative wages in rural areas, as compared to an index based on data from hospital cost reports. 4. In general, relative wages computed from benefits-adjusted BLS data are not substantively different from relative wages computed from hospital data. There are notable exceptions, however, in markets where few hospitals contribute to that market's hospital wage index. 5.Payments to rural referral centers are slightly lower under the index proposed by the committee. Payments to other rural hospitals with special payment status are generally higher (by roughly 1 percent), except for those located in frontier states. 6.The committee found no specific types of hospitals (for example, by teaching status, disproportionate share status, size, or region) that appeared to be disproportionately advantaged or disadvantaged by moving to a more technically accurate index. Key Findings from Physician Payment Simulations 1.As a result of moving to more technically accurate geographic practice cost indexes (GPCIs), the changes in payments would be between 5 and +5 percent in counties where 96 percent of relative value units are billed. Most of the redistribution would be from rural to urban areas and from small urban to large urban areas. 2.The most important intervention to improve accuracy of physician payment adjusters is the move from current payment localities to core-based statistical area (CBSA) markets. 3.GPCIs computed under CBSA markets yield lower relative wages in rural areas, as compared to GPCIs computed under the larger payment localities. 4. Commuter-based smoothing adjustments have a modest effect on the GPCIs for the great majority of counties (99 percent of the wage component of the practice expense GPCIs
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SUMMARY 5 after smoothing are between 0.98 and 1.07), but smoothing serves to partially offset the impact of changing to CBSA markets in rural counties that are adjacent to metropolitan areas. 5.Because many rural areas are also HPSAs, physician payments under the committee's proposed indexes are reduced in most of the rural primary care shortage areas that are currently eligible for Medicare primary care bonus payments. Among medium, high, or full primary care shortage counties in rural areas, estimated payment changes range from a reduction of 26 percent to an increase of 1.7 percent. 6.The impact of the proposed changes would vary primarily between metropolitan and nonmetropolitan county designations rather than across Health Professional Shortage Area designations. The positive effects on metropolitan counties and negative effects on nonmetropolitan counties would be reduced with a 0 percent adjustment for physician work and increased with a 100 percent work adjustment. The impact of a 25 percent adjustment, the current level, would fall within the two extremes. 7.Under the committee's more technically accurate indexes, areas with the highest reductions in payments would be the frontier states, with Alaska experiencing the largest reduction. In summary, the committee found that the effects of implementing its Phase I recommen- dations would make less than a 5 percent change in either direction (increase or decrease) for the large majority of hospital and practitioner services. In aggregate, the payment simulations showed that 88 percent of Medicare discharges from hospitals and 96 percent of physician billings differed less than 5 percent from current payments. However, the committee recognizes that percentages that may seem small when they are aggregated net real differences in pay- ments for clinical services and hospital margins. The committee determined that underserved areas, particularly those that would experience reductions in payment under the proposed payment adjustment changes, would require atten- tion in subsequent analyses and policy changes. Chapter 2 includes a section on provider impact that illustrates the ways in which the payments would change for selected geographic locations. EVIDENCE OF GEOGRAPHIC VARIATION IN ACCESS, QUALITY, AND WORKFORCE DISTRIBUTION The statement of task called for the committee to "evaluate and consider" the effects of the geographic adjustment factors on access, quality, and workforce distribution. Because of the vast number of studies that have addressed these topics over the years, the committee did a targeted search for recent studies that specifically compared access and/or quality of care for beneficiaries in different geographic areas, including regions of the country, metropolitan and nonmetropolitan areas, and local health systems, and then considered how Medicare and other payment policies might improve access for beneficiaries based on the evidence they found. Geographic Variations in Access to Care Generally speaking, most Medicare beneficiaries have good access to care, when defined as services that are readily available and that yield the most favorable outcomes possible. The majority of physicians accept Medicare payment for services, although it can be challenging for
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6 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT beneficiaries to find a new physician in some localities. Racial and ethnic minorities consistently face more barriers in accessing both primary and specialty care, and they are more likely to receive poorer-quality care as measured by a core set of quality measures developed by HHS. Geographic Variations in Quality of Care Hospital quality reporting has been under way for some time, with a recent focus on reducing preventable readmissions as a measure of the quality of care (see Chapter 4). Quality data for physicians and other health professionals will become available by early 2013, to meet requirements of the Medicare Improvements for Patients and Providers Act. Thus far, according to a series of National Healthcare Quality Reports from the Agency for Healthcare Research and Quality, improvements in the quality of care have been disappointingly slow. Quality of care varies considerably within local metropolitan and nonmetropolitan areas, and there is no strong evidence to suggest clear differences in quality of care between metropolitan and nonmetropolitan areas in aggregate. However, the committee recognized that there is considerable concern that variations in payment rates could contribute to variations in health care quality and access across geographic areas. In particular, stakeholders expressed concerns in their testimony to the committee that lower payment rates in rural and underserved areas could have adverse effects on existing problems with quality and access (see Appendix E). Because little published research was available to determine the empirical basis for these concerns, the committee conducted an analysis of data collected as part of the 2010 Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey of fee-for-service Medicare beneficiaries. The analysis showed that metropolitan areas tended to do better on timeliness of access, and nonmetropolitan areas scored higher on communication with doctors and overall satisfaction with physicians. While the study had several limitations, it found little evidence to suggest that revisions in the geographic adjustment factors proposed by the committee would systematically favor areas that currently experience either superior or inferior patient-reported performance on measures of access and quality. In sum, the committee concluded that there are wide discrepancies in access to and qual- ity of care across geographic areas, particularly for racial and ethnic minorities. However, the variations do not appear to be strongly related to differences in or potential changes to fee- for-service payment. Workforce Distribution and Supply The committee was also asked to consider the "level and distribution of the health care workforce and resources, including mobility between metropolitan and nonmetropolitan areas." The health care workforce is unevenly distributed across the country, as are Medicare beneficia- ries themselves.3 More than half of Medicare beneficiaries have one or more chronic conditions, such as diabetes, hypertension, and kidney disease, and their care often requires a combination of primary care and specialty services from multiple clinicians. Of the 1 million practitioners eligible to bill the Medicare program for services delivered to 3 While Medicare beneficiaries make up 15 percent of the population nationwide, up to 60 percent of Medicare beneficiaries in six states (Mississippi, Montana, North Dakota, South Dakota, Vermont, and Wyoming) live in rural areas (KFF, 2010).
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SUMMARY 7 beneficiaries, half are physicians and the other half are nurse practitioners, physical therapists, podiatrists, clinical psychologists, and other professionals. There is a growing body of evidence that shows improved outcomes for beneficiaries when their practitioners coordinate care and function in collaborative teams. Due primarily to limitations in data, the committee's assessment of workforce supply and distribution of health care services was focused on primary care physicians, general surgeons, nurses, nurse practitioners, and physician assistants. The committee documented geographic variation in the practice locations for certain primary care practitioners; for example, nurse practitioners are more likely than physicians to provide primary care services and to choose to practice in shortage areas. However, secondary data used to understand workforce need improvement, and further analysis is needed to understand existing regional differences and the geographic differences in the relationship between primary care or specialist supply and population health. The committee concluded that Medicare beneficiaries in some geographic pockets face persistent access and quality problems, and many of these pockets are in medically underserved rural and inner-city areas. However, geographic adjustment of Medicare payment is not an appropriate approach for addressing problems in the supply and distribution of the health care workforce. The geographic variations in the distribution of physicians, nurses, and physician assistants and local shortages that create access problems for beneficiaries should be addressed through other means. PROGRAMS AND POLICIES TO IMPROVE ACCESS AND QUALITY OF CARE FOR BENEFICIARIES Access to high-quality health care services is not uniform across the United States. The health care workforce varies in size relative to population, and its composition varies both across and within metropolitan and nonmetropolitan areas. The evidence reviewed by the committee suggests that geographic access has been improving, most likely as a result of market forces as well as various workforce policies, but that the supply and distribution of practitioners in some areas continue to be a concern. Evaluation of Workforce Programs and Policies Workforce policies have been in place for many years, some for decades, with the intent of supporting, training, and increasing the production of health professionals who are found to be in short supply. The availability of evidence to determine the effectiveness of these programs varies greatly by program, from none to numerous studies. While residents of underserved communities probably have benefited from the public pro- grams on balance, the programs have been underfunded and have not been implemented on a sufficient scale to have had meaningful effects in all or even some areas. There are many such programs with a relatively small investment per program, especially relative to the size of the U.S. health care sector overall and public programs like Medicare and Medicaid in particular. Similarly, the investment in evaluation of the effectiveness of these programs has been minimal. In general, while a variety of programs attempt to enhance health professional recruit- ment, retention, or both, little is known about which types of policies are most successful in improving access in underserved areas.
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8 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT NEW OPPORTUNITIES TO IMPROVE ACCESS, QUALITY, AND EFFICIENCY The committee sought to determine which policies and programs have been most effective in improving access to hospital and clinical services, improving quality of care, and increasing the supply of practitioners as well as influencing their distribution across geographic areas. The committee also considered ways in which current payment policies might be changed to improve access to care by expanding the reach of the existing workforce. These include the use of telehealth technologies and reevaluating scope-of-practice limitations. Recent Developments in the Use of Telehealth Services One very promising and rapidly developing strategy to improve access and efficiency of care is to provide practicing clinicians with new resources and technology tools that enable them to reach more patients. Telehealth services, which involve using information and communication technologies to provide services when patients and providers are in different locations, are being used by nearly 50 recognized medical subspecialties. These services include videoconferencing, transmission of images, patient portals, consumer health education, remote monitoring of vital signs, nursing call centers, and others. An increasing body of evidence shows that telemedicine or telehealth care management of beneficiaries with chronic diseases, such as diabetes and congestive heart failure, can help reduce preventable rehospitalizations and reduce access barriers related to geographic distance, weather, disability, lack of transportation, or shortages of practitioners in rural areas and other medically underserved urban areas. Scope of Practice Traditionally, discussions of workforce and supply in primary care have focused on how to recruit and retain physicians into primary care rather than specialty care and to provide incen- tives for physicians to practice in underserved areas. As discussions of new care models have evolved, more attention is being paid to the functions and roles of members of care teams and to the nature and extent of their collaborations and working relationships. The scope of practice of various health professions is not only an area of disagreement over professional autonomy between physicians and other health professionals, it also has a major impact on regulatory and payment policies. As of March 2012, 16 states and the District of Columbia have passed laws that remove nurse practitioner practice barriers, enabling them to practice to the full extent of their education and within their scope of preparation, bearing responsibility for the care they deliver, under their own license. Although some of these 16 states have large rural areas (e.g., Alaska, Hawaii, Iowa, North Dakota, Oregon, and Washington), other more restrictive states such as Georgia and Alabama also have significant rural areas, as well as provider shortages that could be alleviated by full use of the available workforce. RECOMMENDATIONS The committee members sought to determine which policies and programs have been most effective in improving access to hospital and clinical services, improving quality of care, and in increasing the supply of practitioners as well as influencing their distribution across the country.
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SUMMARY 9 The evidence review was hampered by the lack of evaluation, mixed results, and methodological challenges in defining quality and workforce measures that also included geographic compari- sons. Therefore, the committee also identified some promising new areas of policy and program development where changes in payment policies have the potential to expand beneficiaries' access to efficient and appropriate health care. The committee offers six recommendations that, if followed, would improve the balance of service across geographic areas. RECOMMENDATION 1: The Medicare program should develop and apply policies that promote access to primary care services in geographic areas where Medicare beneficiaries experience persistent access problems. A focus on primary care is an important part of any effort to build a system of care that will provide efficient, high-value care for all Medicare beneficiaries. This is true for those beneficiaries who require care from multiple specialists because of multiple chronic conditions and also for those who live in medically underserved areas where there are shortages of health professionals, particularly medical specialists. In determining the impact of its Phase I recommendations on vulnerable populations, the committee used HPSAs with shortages of primary care physicians and other practitioners as the standard representation of geographic areas in which beneficiaries may experience access problems due to the undersupply of clinical practitioners. The committee's impact analyses did show that payment to physicians and other clinical practitioners in HPSAs, which are dispro- portionately populated by racial and ethnic minorities, would be adversely impacted by the Phase I recommendations. The committee also analyzed data from the CAHPS survey and did not find evidence that the proposed revisions in the geographic adjustment factors were related to consumer-reported access and quality of care. Based on these analyses and the review of evidence about access and quality of care, the committee concluded that geographic adjustment is not an appropriate tool for achieving policy goals such as improving quality or expanding the pool of providers available to see Medicare beneficiaries. However, Medicare payment policy already provides bonus payments to primary care practitioners and general surgeons who practice in HPSAs. The committee supports these targeted bonus payments and encourages CMS to support other policy adjustments to encour- age the provision of care in underserved areas. RECOMMENDATION 2: The Medicare program should pay for services that improve access to primary and specialty care for beneficiaries in medically underserved urban and rural areas, particularly telehealth technologies. Telehealth involves the use of information and communications technology to exchange information and provide services when patients and practitioners are in different locations. For example, remote patient monitoring, in which electronic devices are used to remotely collect and send real-time personal health information to a clinician, is emerging as a standard of care that improves access and clinical efficiencies and reduces the travel burden on beneficiaries. Currently, Medicare pays for telehealth services when provided by qualified providers to beneficiaries in rural areas, but individuals and facilities in medically underserved metropolitan areas are not eligible for Medicare payment for telehealth services. While the committee recog-
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10 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT nizes the importance of ensuring that all telehealth providers are appropriately credentialed, the committee calls for changes in CMS payment policy to support telehealth services that improve access for all beneficiaries, and particularly for those in underserved urban and rural areas. RECOMMENDATION 3: To promote access to appropriate and efficient primary care services, the Medicare program should support policies that would allow all quali- fied practitioners to practice to the full extent of their educational preparation. The committee reviewed multiple sources of workforce data and found clear documenta- tion of the need for primary care practitioners in general, and specifically in rural areas. There is evidence that primary care NPs choose to practice in rural areas more than their physician counterparts. There are many inconsistencies in state laws regulating scope of practice, and NPs are more likely to locate in rural areas in states with more progressive, less restrictive regulations. Given the shortage of primary care providers in the United States and specifically in rural areas, the committee agrees that it would be reasonable to remove barriers in Medicare and state licensing language so all qualified practitioners are able to practice to the full extent of their educational preparation in providing needed services for Medicare beneficiaries. RECOMMENDATION 4: The Medicare program should reexamine its policies that provide location-based adjustments for specific groups of hospitals, and modify or discontinue them based on their effectiveness in ensuring adequate access to appropriate care. Several groups of hospitals currently receive special treatment in determining Medicare payment, on the basis that extra payment is necessary to preserve beneficiaries' access to appropriate care in the areas they serve: critical access hospitals, sole community hospitals, Medicare-dependent hospitals, low-volume hospitals, and rural referral centers. The criteria for qualifying for special treatment are generally not consistently stated or applied, nor have access benefits for beneficiaries been consistently demonstrated. It may be advisable over time to com- bine existing programs--or establish new ones to replace existing ones--to protect access to appropriate high-quality care for Medicare beneficiaries in different areas of the United States. RECOMMENDATION 5: Congress should fund an independent ongoing entity, such as the National Health Care Workforce Commission, to support data collection, research, evaluations, and strategy development, and make actionable recommen- dations about workforce distribution, supply, and scope of practice. The committee was tasked with assessing "the effect of the adjustment factors on the level and distribution of the health care workforce and resources, including recruitment and reten- tion, taking into account mobility between urban and rural areas." That task was made difficult by the lack of objective, longitudinal research on the workforce. There is a serious lack of clear and consistent data collected in a uniform manner over time or that consider more than one profession or discipline. Recognizing these problems and constraints, the committee recommends the funding of an organization independent of the programs that can focus policy questions, combine view- points, prioritize policy choices, collect more useful data, coordinate evaluation and assessment
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SUMMARY 11 projects, and evaluate cross-cutting policy options. One such body, the Workforce Commission established in the Affordable Care Act, has already been appointed but has not yet been funded. RECOMMENDATION 6: Federal support should facilitate independent external evalu- ations of ongoing workforce programs intended to provide access to adequate health services for underserved populations and Medicare beneficiaries. These programs include the National Health Service Corps, Title VII and VIII programs under the Public Health Service Act, and related programs intended to achieve those goals. The committee conducted a comprehensive literature review of public programs designed to improve the geographic distribution of health care professionals. Virtually all of the studies dealt with physicians, and most studies focused on physician retention instead of their original recruitment to underserved areas or on their practice location decisions. The committee asks for much more rigorous independent evaluation of these programs to identify which program strategies are most effective. These evaluations should not be limited to physicians, and they should focus on decision making of health professionals and on impacts on populations who live in underserved areas. CONCLUSION Through its recommendations presented in its Phase I and Phase II reports, the committee has fulfilled its charge to recommend improvements in the accuracy of how Medicare's fee-for- service geographic payment adjustments are calculated. Changes in fee-for-service payments that encourage greater coordination of care may be helpful in promoting outcome-based delivery system changes. The committee's Phase I recommendations to harmonize hospital and practitioner labor market areas and data sources are examples of ways that fee-for-service payment changes may encourage delivery system improvements. Consistent with this harmonization is the recognition in Phase II of the importance of the health care workforce in achieving access and quality goals. REFERENCE KFF (Kaiser Family Foundation). 2010. Medicare chartbook, 4th ed. http://www.kff.org/upload/8103.pdf (accessed July 3, 2012).
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