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PAPERBACK price:$58.00 add to cart Rights & Permissions Free PDF Access Sign in to download PDF book and chapters Free Resources PDF SUMMARY Display this book on your site! Related Titles Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy, Second Edition Medicare Laboratory Payment Policy: Now and in the Future Other Related Titles Geographic Adjustment in Medicare Payment: Phase II: Implications for Access, Quality, and Efficiency (2012) Board on Health Care Services (HCS) Citation Manager Export the bibliographic data for this book in your chosen format Web Search Builder Use this book's key terms to search within this book, across our collection, or across the Web. Skim This Chapter Skim this chapter and use this chapter's key terms to search within this book. Reference Finder Paste in your own text to find books that relate to your topic. Citation Manager Committee on Geographic Adjustment Factors in Medicare Payment, Board on Health Care Services, Institute of Medicine. "Index." Geographic Adjustment in Medicare Payment: Phase II: Implications for Access, Quality, and Efficiency. Washington, DC: The National Academies Press, 2012. Please select a format: Page 209   E-mail Share on facebook Facebook Share on delicious Delicious Share on stumbleupon Stumble Share on twitter Twitter More Sharing ServicesMore Page 209 Front Matter (R1-R22) Summary: Implications of Geographic Adjustment for Access, Quality, and Efficiency of Care (1-12) 1 Introduction and Overview (13-22) 2 Payment Simulations (23-50) 3 Evidence of Geographic Variation in Access, Quality, and Workforce Distribution (51-90) 4 Programs and Policies to Improve Access and Quality of Care for Beneficiaries (91-124) 5 Observations on the Larger Policy Context (125-134) 6 Recommendations (135-142) Appendix A-1: Technical Approach to Payment Simulations: IOM Committee Recommendations for Hospital Wage Index and Physician Geographic Adjustment Factors (143-172) Appendix A-2: Payment Simulations: Data Tables (173-174) Appendix B: Methods for the Analysis of Associations of Quality Measures with Payments in Chapter 3 (175-182) Appendix C: Quality Assurance for RTI Payment Simulations (183-186) Appendix D: Public Session: Workforce, Access, and Innovation Policy Levers for Geographic Adjustment In Medicare Payment (187-188) Appendix E: Exchange of Letters Between House of Representatives Quality Coalition and Committee Chair Frank Sloan (189-194) Appendix F: Committee and Staff Biographies (195-208) Index (209-216)

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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