Index

[Page numbers followed by b, f, n, or t, refer to boxed text, figures, footnotes, or tables, respectively.]

A

Access to care

cost of care as barrier to, 54

current system performance, 5–6, 7, 53–54, 61, 82, 91

definition and measures of, 17b, 51, 52t, 58–59

delivery system reforms to improve, 114–117

determinants of, 18, 19, 99, 132

disparities in, 57, 129–130

expected outcomes of Phase I recommendations, 2–3, 6, 61–62, 136–137

geographic adjustment and, 2–3, 5–6, 7, 14, 49, 51, 61–62, 82–83, 136

in Health Professional Shortage Areas, 40, 55

health workforce supply and distribution as factor in, 17, 18, 54–55, 66–67, 136

locating new physician as indicator of, 54

Medicare fee schedule as factor in, 126–127

Medicare physician participation rates and, 56–57

Medicare policies for maintaining, 92–96, 93–94t, 119

in metropolitan and nonmetropolitan areas, 55–56, 82

opportunities to improve, 8, 65, 74–82

patient travel distance as measure of, 65, 66, 99

payment policy as factor in, 18

physician payment policies and, 91

quality of care and, 59

recommendations for improving, 9–10, 11, 137–138, 140–141

study goals, 2b, 14–15, 15b, 51

underserved and vulnerable populations, 6, 7, 53, 55–56, 57–58, 82, 83, 129–130, 136–137

See also Specialty medicine, access to

Accountable care organizations, 114–116, 131

Advance payment accountable care organizations, 115–116

Advanced practice nurses, 65, 72, 81

Affordable Care Act, 39, 56b, 98, 117, 119, 127

Affordable Health Care for America Act, 1, 14

Agency for Healthcare Research and Quality (AHRQ), 6, 58

Alaska, 5, 37, 38–39, 47, 48–49b, 57, 73

Alien physician program, 111–112

American Recovery and Reinvestment Act, 79

Area Health Education Centers, 97

Area Resource File, 152–154

B

Balanced Budget Act, 139

Benefits in provider compensation, 24n, 146, 148–150, 149t

Bureau of Labor Statistics

employee benefits data, 24n

hospital wage index based on data from, 4

Occupational Employment Statistics, 66

in simulations of Phase I recommendations, 4, 27, 28f, 30–31, 49, 146–148



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Index [Page numbers followed by b, f, n, or t, refer to boxed quality of care and, 59 text, figures, footnotes, or tables, respectively.] recommendations for improving, 910, 11, 137 138, 140141 study goals, 2b, 1415, 15b, 51 A underserved and vulnerable populations, 6, 7, 53, 5556, 5758, 82, 83, 129130, 136137 Access to care See also Specialty medicine, access to cost of care as barrier to, 54 Accountable care organizations, 114116, 131 current system performance, 56, 7, 5354, 61, 82, Advance payment accountable care organizations, 91 115116 definition and measures of, 17b, 51, 52t, 5859 Advanced practice nurses, 65, 72, 81 delivery system reforms to improve, 114117 Affordable Care Act, 39, 56b, 98, 117, 119, 127 determinants of, 18, 19, 99, 132 Affordable Health Care for America Act, 1, 14 disparities in, 57, 129130 Agency for Healthcare Research and Quality (AHRQ), expected outcomes of Phase I recommendations, 6, 58 23, 6, 6162, 136137 Alaska, 5, 37, 3839, 47, 4849b, 57, 73 geographic adjustment and, 23, 56, 7, 14, 49, Alien physician program, 111112 51, 6162, 8283, 136 American Recovery and Reinvestment Act, 79 in Health Professional Shortage Areas, 40, 55 Area Health Education Centers, 97 health workforce supply and distribution as factor Area Resource File, 152154 in, 17, 18, 5455, 6667, 136 locating new physician as indicator of, 54 Medicare fee schedule as factor in, 126127 B Medicare physician participation rates and, 5657 Medicare policies for maintaining, 9296, 9394t, Balanced Budget Act, 139 119 Benefits in provider compensation, 24n, 146, 148150, in metropolitan and nonmetropolitan areas, 5556, 149t 82 Bureau of Labor Statistics opportunities to improve, 8, 65, 7482 employee benefits data, 24n patient travel distance as measure of, 65, 66, 99 hospital wage index based on data from, 4 payment policy as factor in, 18 Occupational Employment Statistics, 66 physician payment policies and, 91 in simulations of Phase I recommendations, 4, 27, 28f, 3031, 49, 146148 209

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210 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT C recommendations from Phase I report, 1, 13, 24 study goals, 1 California, 4647, 74 use of core-based statistical areas, 4, 34 Centers for Medicare & Medicaid Services, 1, 14, 92 on workforce supply and distribution, 7, 6566, Chronic care patients, 6, 19, 7677 118119 Community health centers, 9697 Delivery of care Commuting between market areas, 45, 27, 29b, 33b, characteristics of well-functioning system, 5253 34n, 37, 37n, 4546, 47, 49, 50, 150152. determinants of quality in, 18, 19 See also Smoothing labor market borders and health care labor markets as factor in, 18 payment areas reform initiatives to improve access and quality, Comprehensive Primary Care Initiative, 117 114117, 131132 Congress, recommendations for, 1011, 139140 study goals, 2b, 15b, 18 Conrad-30 Programs, 111 See also Access to care Consumer Assessment of Healthcare Providers and Department of Health and Human Services, 1, 13, 103, Systems, 6, 51, 5962, 136 129130 Consumer satisfaction, 5962, 60t, 100 Disabilities, current Medicare coverage, 1, 13 Coordination of care, 7, 11, 19, 59, 114, 115, 117, 119 Disparities Core-based statistical areas in access to care, 57, 129130 mapping Bureau of Labor Statistics data to, in metropolitan and nonmetropolitan areas, 5556, 63 146147 in quality of care, 82, 102, 106 outcomes of simulations based on Phase I recommendations, 4, 34, 3738, 4546, 50 smoothing methodology, 150152, 151t E Cost of care as barrier to access, 54 Electronic health records, 103104 benefits of telehealth services, 81 Emergency Health Personnel Act, 108 care transitions, 117 geographic variation in practice input costs, 104, 107 F health care labor markets as factor in, 18 Florida, 45 hospital readmissions, 101 Frontier states, 4, 5, 23n, 30, 31, 33b, 3839, 4344, Medicare reimbursement reform initiatives, 131132 132 Critical access hospitals, 10, 9294, 92n, 139 Future of Nursing, The, 82, 138139 Cross-subsidization, 23, 23n G D Geographic adjustment, generally Data sources current Medicare system, 1, 13 for commuting-based smoothing, 29b effects on health care access and quality, 23, 56, for computation of hospital wage index in Phase I 7, 14, 49, 51, 6162, 8283, 84, 104, 119, 125, simulations, 155156 136 for computation of physician payments in Phase I expected outcomes of Phase I recommendations, simulations, 159 25, 1920 for construction of geographic practice cost indexes, Medicare adjustments for hospitals in isolated areas, 34n, 35b 9296 for construction of hospital wage index, 32b Medicare fee schedule before, 126127 on effectiveness of programs to improve access to recommendations from Phase I report, 24, 25b care, 11, 140141 study goals, 1, 1314, 19 Health Professional Shortage Areas, 3, 40 terminology, 1517, 16b, 17b impact of Bureau of Labor Statistics data on Phase I value-based reimbursement and, 131132 simulations, 4, 27, 28f, 3031, 49 See also Geographic adjustment factors; Geographic quality of care, 6, 5961 practice cost indexes; Hospital wage index recommendations for health workforce data Geographic adjustment factors collection, 1011, 139141 definition and computation, 35b

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INDEX 211 effects on health workforce supply and distribution, methodology for analysis of payment rate mediation 9192 of quality of care in, 175178, 179t, 181t methodology for analysis of payment rate mediation methodology for designating, 56b of quality of care, 175178, 181t outcomes of simulations based on Phase I outcomes of simulations based on Phase I recommendations, 24, 5, 9, 20, 3944, 41t, 50, recommendations, 25, 6, 9, 1920, 4849b, 62, 125126, 136137, 170t 6162, 168t primary care bonus payment program in, 9798, study goals, 2b, 1415, 15b, 135 119 value-based reimbursement and, 131132 shortcoming of, as data source, 3, 40 See also Geographic adjustment, generally; Surgical Incentive Payment, 98 Geographic practice cost indexes; Hospital wage See also Primary care bonus payment program index Health Resources and Services Administration, 92, 127 Geographic Adjustment in Medicare Payment: Phase I: Health workforce supply and distribution Improving Accuracy, 1, 25, 13, 14, 135. See also access to care and, 17, 18, 5455, 6667, 136 Simulation of Phase I recommendations commuting between market areas, 45, 27, 29b Geographic practice cost indexes (GPCIs) current programs to improve, 11, 119, 140141 accuracy, 24 current status, 67, 64, 65f, 6667, 91, 9899 benefits index, 148150, 149t data sources, 7, 10, 6566, 118, 119, 139140 as budget-neutral in simulations, 24, 161163 determinants of practitioner location decisions, computation of, 34n, 35b, 44 5455, 64, 104107 effects of removing index floors, 3839 effects of geographic adjustment factors, 9192 effects on health care access and quality, 61 effects of Medicare's national fee schedule, 126127 function, 35b expected outcomes of Phase I recommendations, methodology for analysis of payment rate mediation 8283 of quality of care, 175178, 181t geographic distribution, 66, 6774, 68f, 69f, 70f, outcomes of simulations based on Phase I 72f, 74f, 75f, 77f, 82 recommendations, 45, 2327, 26f, 3147, 36f, Medicare participation and, 67, 19 50, 6162, 125126, 167f, 169171t, 172t national targets, 117 payment areas, in simulation of Phase I need for government entity to oversee, 1011, recommendations, 150, 151t 118119, 139140 in Phase I simulation methodology, 146, 159160, outcomes of programs and policies to improve, 7, 161 107114, 136 proxy professions in calculation of, 34n, 44 policy considerations affecting, 117118 recommendations from Phase I report, 24, 25b, 26t practitioner population included in assessment of, in shortage areas, 3944, 4144 16, 17b smoothing adjustments, 37, 37n, 50 programs to encourage clinical practice in statewide versus nonstatewide payment localities, underserved areas, 96100, 107114 3738, 45 projections, 64, 66 quality of care and, 6667, 136 recommendations for improving, 1011, 139141 H research needs, 99100, 113114 scope of practice issues and, 8, 10, 8182 H-1B visa, 111 strategies for improving, 8, 64, 65, 92 Health Care Workforce Commission, 118119 study goals, 2b, 1415, 15b, 18, 19 Health Information Technology for Economic and telehealth credentialing, 80 Clinical Health, 104, 104n HITECH Act, 104, 104n Health Professional Shortage Areas Hospital Compare, 102 application, 3940, 55, 8384, 97 Hospital Consumer Assessment of Healthcare Providers beneficiary population, 4042, 41t, 55, 56f, 58f, 64, and Systems, 100 84 Hospital Inpatient Quality Reporting Program, 100 definition, 3, 3n, 1617, 17b, 55, 56b Hospital readmissions, 78, 100102 determinants of practitioner location decisions, 64 Hospital wage index health care access and quality in, 61 accuracy, 24 mapping methodology for Phase I simulations, benefits index, 148150, 149t 152155, 156f, 156t, 157t

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212 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT as budget-neutral in simulations, 24, 161163 M computation of, 3233b, 155158, 160161 fixed-weight index, 147148, 148f Maine, 56 function, 32b Massachusetts, 46, 47, 56 hospitals with special payment status, 10, 3031, Medical home concept, 114 32t, 33t, 139 Medicare location-based adjustments for special groups of chronic conditions among beneficiaries of, 6, 19, hospitals, 10 7677 outcomes of simulations based on Phase I consumer satisfaction, 5962, 60t, 100 recommendations, 4, 1920, 2331, 26f, 28f, coverage, 1, 13, 5657 34t, 4447, 4850, 136 current access to care for beneficiaries of, 56, 7, in Phase I simulation methodology, 146 5354, 82, 91 recommendations from Phase I report, 24, 25b, current health care workforce, 64 26t current quality of care in, 5863 year-to-year changes, 34t current spending, 1, 13, 78 Household income, 39, 171t delivery system reforms to promote access and quality, 114117 fee setting policies, 126127 I geographic distribution of beneficiaries, 6n influence on health workforce supply and Idaho, 101 distribution, 114, 126, 136 Illinois, 101 Part B services, 42, 54, 5657, 82, 9798 Immigration law, 111112 policies to maintain access to care, 9296, 9394t, Inpatient Prospective Payment System 119 hospitals with special payment status, 3031, 32t, practitioner population, 67, 19, 57 33t, 139 programs to improve quality of care, 119 impact of Phase I recommendations, 25, 27, 28f, 100104 163167f projected growth, 81 Medicare adjustments for hospitals in isolated areas, recommendations for improving access to services, 9495 910, 137139 International medical students, 111112 reimbursement for nonphysician health professionals, 117118 reimbursement reforms to improve access and J quality, 91, 131132 J-1 waiver program, 111112 shared savings program, 115 subsidization of graduate medical education, 127129 L supplemental coverage, 54 telehealth services coverage, 78t, 7981 Labor markets See also Simulation of Phase I recommendations computation of geographic practice cost indexes, Medicare Advantage, 54n 35b Medicare Cost Reports, 32b computation of hospital wage index, 3233b Medicare-dependent hospitals, 10, 31, 92, 95, 139 definition, 16b Medicare Improvements for Patients and Providers Act, statewide versus nonstatewide payment localities, 6, 102 3738 Medicare Modernization Act, 95 See also Health workforce supply and distribution; Medicare Payment Advisory Commission (MedPAC), Smoothing labor market borders and payment 5354, 127 areas Medigap, 54n Licensure, professional, 8, 6465, 71, 8182, 107, 138 Metropolitan and nonmetropolitan areas Loan forgiveness programs, 107, 108, 110111, access to care, 5556, 82 113114, 119 determinants of practitioner location decisions, Louisiana, 101 104107 Low-volume hospitals, 10, 92, 95, 96, 139 effects of Medicare's national fee schedule on Lugar hospitals, 30 physician location decisions, 127

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INDEX 213 in frontier states, 30 O health workforce distribution, 64, 66, 6769, 69f methodology for analysis of payment rate mediation Ohio, 46 of quality of care, 175178, 180t Oregon, 101 outcomes of simulations based on Phase I recommendations, 4, 5, 27, 3437, 38f, 39, 4142, 4447, 49, 50, 136, 163f, 165t, 167f, P 169t, 170t Patient Protection and Affordable Care Act. See primary care billings, 127, 128f Affordable Care Act quality of care variation between and within, 6, Payment policy 6364, 180t, 181t effectiveness of current programs to encourage statewide versus nonstatewide payment localities, practice in underserved areas, 107114 37 effects on health care access and quality, 6, 8, 11, study goals, 2b, 15b, 18 18, 91 workforce distribution and supply in, 6, 7, 15b evidence of overpayment or underpayment, 23 See also Rural areas to improve quality of care, 100102, 116117 Micropolitan areas, 56, 63 influence on practitioner location decisions, 105107 Minnesota, 45, 56 loan forgiveness programs, 107, 108, 110111, 113114 Medicare reimbursement reforms to improve access N and quality, 131 National Health Care Workforce Commission, 10, 11, Medicare's fee setting policies, 126127 139140 methodology for analysis of payment rate mediation National Health Disparities Report, 59 of quality of care, 175178 National Health Quality Report, 59 programs to encourage clinical practice in National Health Service Corps, 11, 108110, 113, 127, underserved areas, 34, 9698 136, 140141 recommendations from Phase I report, 24, 25b, 26t National Healthcare Quality Report, 102 reimbursement for nonphysician health National Impact Assessment of Medicare Quality professionals, 117118 Measures, 103 study goals, 2b, 8, 15b, 18, 19 National Institute for Minority Health and Health value-based purchasing, 116117, 131 Disparities, 130 See also Geographic adjustment, generally; National Institutes of Health, 130 Geographic practice cost indexes; Hospital wage National Quality Strategy, 102104 index; Primary care bonus payment program National Strategy for Quality Improvement in Health Care, Pennsylvania, 47 103 Phase I. See Geographic Adjustment in Medicare Payment: New England City and Town Areas, 146147 Phase I: Improving Accuracy New Hampshire, 73 Physician assistants, 66, 71, 7374, 76f, 77f, 82, 114, New Jersey, 7778, 101 116, 117118, 129 North Dakota, 42, 43f Physician Compare, 102 Nurse practitioners Physician education and training current and projected supply, 66 influence on practice location decisions, 107108, in delivery system reforms to promote access and 112113 quality, 114, 115, 116 shortcomings of data on, 118 health care delivery role, 71, 84 subsidization of graduate medical education, Medicare payment policy, 117118 112113, 126, 127129 minority population utilization of, 129 Physician Quality Reporting System, 102 recommendations for scope of practice, 10, Pioneer accountable care organizations, 115 138139 Policy adjustments scope of practice issues, 8, 10, 8182, 83b cross-subsidization, 23, 23n supply and geographic distribution, 7173, 74f, definition, 16b 75f recommendations from Phase I report, 24 training, 71 rural floor adjustments as, 30 in simulations of Phase I recommendations, 4, 20, 24, 48

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214 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT Population health in Health Professional Shortage Areas, 179t, 181t effect of provider payment policies on, 92 health workforce supply and, 6667, 136 racial and ethnic disparities, 126, 129130 hospital readmission rates, 78, 100102 study goals, 2b, 1415, 15b methodology for analysis of payment rate effects, Premier Hospital Quality Incentive Program, 103b 175178 Primary care in metropolitan and nonmetropolitan areas, 6, in community health centers, 9697 6364, 180t, 181t coordination of care in, 117 National Quality Strategy, 102104 definition, 17, 17b, 53 physician payment policy to improve, 102 influences on physicians' career decisions, 107108 regional variation in, 6263 outcomes of Phase I simulations by county percent strategies for improving, 8, 100104 of primary care relative value units, 172t study goals, 2b, 1415, 15b, 51 physician caseloads, 99 underserved populations, 63, 82 physician supply and geographic distribution, 7, value-based purchasing, 116117 58f, 6769, 70f, 73t, 99 practitioner earnings in, 106b recommendations for improving access to, 910, R 137139 Racial and ethnic minorities reimbursement for nonphysician health access to care, 23, 6, 53, 5556, 5758, 82, 83, professionals, 117118 129 scope of practice regulations, 10, 8182, 84, hospital readmission rates, 101102 138139 outcomes of Phase I recommendations for, 23, in a well-functioning health care system, 5253, 84 129, 136137, 171t Primary care bonus payment program population health research, 126, 129130 bonus, 42, 9798 quality of care received by, 63, 82, 83 disbursement methodology, 3941 strategies to reduce health care disparities, 129130, disbursements to date, 98 130b effectiveness, 98, 119, 127 study goals, 23 eligibility of health professionals for, 34, 16, 17, 98 utilization of nonphysician health professionals, 129 geographic distribution, 4042 Recommendations to offset geographic practice cost index reductions, commuter smoothing, 29b 4243 from Geographic Adjustment in Medicare Payment: recommendations for, 9, 137 Phase I, 1, 25, 13, 24, 25b, 135 See also Health Professional Shortage Areas hospitals with special payment status, 10, 139 Public Health Service Act, 11, 107n, 127, 140 to improve access to care, 910, 11, 137139, Puerto Rico, 47, 48b, 49b 140141 to improve workforce supply and distribution, 1011, 139140 Q See also Simulation of Phase I recommendations Quality of care Recruitment and retention of health care workforce access to care and, 59 future challenges, 64 in community health centers, 9697 study goals, 2b, 15b current data collection and dissemination, 6 in underserved areas, effectiveness of programs to current system performance, 6, 5864, 60t, 82 improve, 11, 107114, 140141 definition and measures of, 17b, 19, 20t, 5152, Registered nurses, 70, 72f 52t, 5960, 100 Relative value units, 4, 2526, 35b, 127, 128f, 150 delivery system reforms to improve, 114117 Rent costs, 24n, 35b, 145 determinants of, 132 Resource-based Relative Value Scale, 127 effectiveness of incentive payment programs, 103b, Rhode Island, 56 119 Rural areas effects of geographic adjustment, 23, 6, 7, 14, 51, determinants of practitioner location decisions, 6162, 8283, 84, 104, 119, 125, 136 104105, 107108, 112 expected outcomes of Phase I recommendations, distribution of Medicare beneficiaries, 18n 23, 6, 6162, 125 health workforce supply, 64, 67, 6869, 71, 73

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INDEX 215 hospitals with special payment status, 10, 3031, methodology, 23, 145163 33t, 139 outcomes by household income, 171t Medicare payment policies for hospitals serving, outcomes for frontier states, 4, 5, 3839, 132 9294 outcomes for racial and ethnic minorities, 23, 129, outcomes of programs to encourage practice in, 136137, 171t 107114 outcomes in metropolitan and nonmetropolitan outcomes of simulations based on Phase I areas, 45, 27, 3437, 38f, 39, 49, 50, 132, 136, recommendations, 45, 27, 38, 38f, 39, 132, 163f, 165t, 167f 171t outcomes in shortage areas, 24, 5, 9, 20, 3944, population distribution, 68 41t, 50, 62, 125126, 132, 137 recommendations for improving access to care in, physician payment computations, 146, 159160, 910, 137139 161 scope of practice issues for health care workforce in, physician payment outcomes, 45, 2327, 26f, 82 3147, 36f, 50, 6162, 125126, 136, 167f, See also Metropolitan and nonmetropolitan areas 169171t, 172t Rural floor adjustment, 4, 23n, 2930, 33b, 45, 4647, policy adjustments in, 4, 20, 24, 48 49 quality assurance and quality control in preparation Rural Health Care Pilot Program, 7879 of, 183186, 186t Rural referral centers, 4, 31, 49, 92, 95, 96 quality of care outcomes, 125 recommendations for, 10, 139 rural floor adjustments in, 4, 2930, 4647 RuralUrban Continuum Code, 39, 6061, 62, 153, scope of analysis, 24 176, 177, 178, 180t, 181t, 182t smoothing labor market borders and payment areas in, 45, 27, 4546, 47, 49, 50, 150152, 151t, 152t, 153f, 154t S use of core-based statistical areas, 4, 34, 3738, 4546, 50 Scope of practice issues, 8, 8182, 83b, 138139 Smoothing labor market borders and payment areas Screening, 7778 computation of geographic practice cost indexes, Shared savings, 115, 131 34n, 37, 37n Shortage areas. See Health Professional Shortage Areas computation of hospital wage index, 33b Simulation of Phase I recommendations methodology, 29b, 150152, 151t, 152t, 153f, access to care, 23, 6, 8283, 136137 154t, 157 aggregate geographic adjustment factors changes, outcomes of simulations based on Phase I 168t recommendations, 45, 2728, 37, 37n, 4546, budget neutrality in, 24, 161163, 162t 47, 49, 50 distribution of effects across payment areas, 2627 recommendations, 29b effects in counties by percent of primary care Social Security Act, 2b, 15b, 97 relative value units, 172t Sole community hospitals, 10, 31, 92, 9495, 96, examples of provider impact, 4447 139 hospital adjustment status effects, 166t Specialty medicine, access to hospital payment computations, 146, 155158, geographic variation in, 5354, 66, 67, 99, 105, 160161 114 hospital payment outcomes, 4, 1920, 2331, 26f, for minority populations, 58, 82, 84 28f, 4850, 125, 136 nurse practitioners and physician assistants and, 71, hospital size effects, 167t 72, 84 hospitals with special payment status, 3031, 32t, practitioner career decisions and, 104, 106b, 33t 107108, 112 impact of Bureau of Labor Statistics data, 4, 27, 28f, recommendations for improving, 910, 137138 3031, 49 telemedicine and, 75, 76, 84 Inpatient Prospective Payment System outcomes, trends, 69, 105 25, 27, 28f, 163167f Subsidization of graduate medical education, 112113, key findings, 4850 126, 127129 mapping of Health Professional Shortage Areas, Surgeons, 69, 71f, 84, 98 152155, 156f, 156t, 157t

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216 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT T programs to encourage clinical practice in, 96100 recommendations for improving access to care in, Telehealth technologies 910, 11, 137138, 140141 credentialing of providers for, 80 study goals, 135 current implementation, 8, 910, 7475, 138 underserved populations versus, 1617 definition, 8, 9, 138 See also Health Professional Shortage Areas effectiveness, 8, 7778 Utah, 101 future prospects, 8081 infrastructure, 7879 Medicare payment provisions, 7980, 81 V recommendations for, 910, 84, 137138 Transitional care, 114, 117 Value-based purchasing, 116117, 131 Virginia, 47 U W Underserved areas influences on physicians' career decisions, 107108, Washington state, 74 112113 West Virginia, 45 outcomes of programs to encourage clinical practice in, 7, 11, 108114, 140141