[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
C
California, 46–47, 74
Centers for Medicare & Medicaid Services, 1, 14, 92
Chronic care patients, 6, 19, 76–77
Community health centers, 96–97
Commuting between market areas, 4–5, 27, 29b, 33b, 34n, 37, 37n, 45–46, 47, 49, 50, 150–152. See also Smoothing labor market borders and payment areas
Comprehensive Primary Care Initiative, 117
Congress, recommendations for, 10–11, 139–140
Conrad-30 Programs, 111
Consumer Assessment of Healthcare Providers and Systems, 6, 51, 59–62, 136
Consumer satisfaction, 59–62, 60t, 100
Coordination of care, 7, 11, 19, 59, 114, 115, 117, 119
Core-based statistical areas
mapping Bureau of Labor Statistics data to, 146–147
outcomes of simulations based on Phase I recommendations, 4, 34, 37–38, 45–46, 50
smoothing methodology, 150–152, 151t
Cost of care
as barrier to access, 54
benefits of telehealth services, 81
care transitions, 117
geographic variation in practice input costs, 104, 107
health care labor markets as factor in, 18
hospital readmissions, 101
Medicare reimbursement reform initiatives, 131–132
Critical access hospitals, 10, 92–94, 92n, 139
Cross-subsidization, 23, 23n
D
Data sources
for commuting-based smoothing, 29b
for computation of hospital wage index in Phase I simulations, 155–156
for computation of physician payments in Phase I simulations, 159
for construction of geographic practice cost indexes, 34n, 35b
for construction of hospital wage index, 32b
on effectiveness of programs to improve access to care, 11, 140–141
Health Professional Shortage Areas, 3, 40
impact of Bureau of Labor Statistics data on Phase I simulations, 4, 27, 28f, 30–31, 49
quality of care, 6, 59–61
recommendations for health workforce data collection, 10–11, 139–141
recommendations from Phase I report, 1, 13, 24
study goals, 1
use of core-based statistical areas, 4, 34
on workforce supply and distribution, 7, 65–66, 118–119
Delivery of care
characteristics of well-functioning system, 52–53
determinants of quality in, 18, 19
health care labor markets as factor in, 18
reform initiatives to improve access and quality, 114–117, 131–132
study goals, 2b, 15b, 18
See also Access to care
Department of Health and Human Services, 1, 13, 103, 129–130
Disabilities, current Medicare coverage, 1, 13
Disparities
in access to care, 57, 129–130
in metropolitan and nonmetropolitan areas, 55–56, 63
in quality of care, 82, 102, 106
E
Electronic health records, 103–104
Emergency Health Personnel Act, 108
F
Florida, 45
Frontier states, 4, 5, 23n, 30, 31, 33b, 38–39, 43–44, 132
Future of Nursing, The, 82, 138–139
G
Geographic adjustment, generally
current Medicare system, 1, 13
effects on health care access and quality, 2–3, 5–6, 7, 14, 49, 51, 61–62, 82–83, 84, 104, 119, 125, 136
expected outcomes of Phase I recommendations, 2–5, 19–20
Medicare adjustments for hospitals in isolated areas, 92–96
Medicare fee schedule before, 126–127
recommendations from Phase I report, 24, 25b
study goals, 1, 13–14, 19
terminology, 15–17, 16b, 17b
value-based reimbursement and, 131–132
See also Geographic adjustment factors; Geographic practice cost indexes; Hospital wage index
Geographic adjustment factors
definition and computation, 35b
effects on health workforce supply and distribution, 91–92
methodology for analysis of payment rate mediation of quality of care, 175–178, 181t
outcomes of simulations based on Phase I recommendations, 2–5, 6, 9, 19–20, 48–49b, 61–62, 168t
study goals, 2b, 14–15, 15b, 135
value-based reimbursement and, 131–132
See also Geographic adjustment, generally; Geographic practice cost indexes; Hospital wage index
Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy, 1, 2–5, 13, 14, 135. See also Simulation of Phase I recommendations
Geographic practice cost indexes (GPCIs)
accuracy, 24
benefits index, 148–150, 149t
as budget-neutral in simulations, 24, 161–163
computation of, 34n, 35b, 44
effects of removing index floors, 38–39
effects on health care access and quality, 61
function, 35b
methodology for analysis of payment rate mediation of quality of care, 175–178, 181t
outcomes of simulations based on Phase I recommendations, 4–5, 23–27, 26f, 31–47, 36f, 50, 61–62, 125–126, 167f, 169–171t, 172t
payment areas, in simulation of Phase I recommendations, 150, 151t
in Phase I simulation methodology, 146, 159–160, 161
proxy professions in calculation of, 34n, 44
recommendations from Phase I report, 24, 25b, 26t
in shortage areas, 39–44, 41–44
smoothing adjustments, 37, 37n, 50
statewide versus nonstatewide payment localities, 37–38, 45
H
H-1B visa, 111
Health Care Workforce Commission, 118–119
Health Information Technology for Economic and Clinical Health, 104, 104n
Health Professional Shortage Areas
application, 39–40, 55, 83–84, 97
beneficiary population, 40–42, 41t, 55, 56f, 58f, 64, 84
definition, 3, 3n, 16–17, 17b, 55, 56b
determinants of practitioner location decisions, 64
health care access and quality in, 61
mapping methodology for Phase I simulations, 152–155, 156f, 156t, 157t
methodology for analysis of payment rate mediation of quality of care in, 175–178, 179t, 181t
methodology for designating, 56b
outcomes of simulations based on Phase I recommendations, 2–4, 5, 9, 20, 39–44, 41t, 50, 62, 125–126, 136–137, 170t
primary care bonus payment program in, 97–98, 119
shortcoming of, as data source, 3, 40
Surgical Incentive Payment, 98
See also Primary care bonus payment program
Health Resources and Services Administration, 92, 127
Health workforce supply and distribution
access to care and, 17, 18, 54–55, 66–67, 136
commuting between market areas, 4–5, 27, 29b
current programs to improve, 11, 119, 140–141
current status, 6–7, 64, 65f, 66–67, 91, 98–99
data sources, 7, 10, 65–66, 118, 119, 139–140
determinants of practitioner location decisions, 54–55, 64, 104–107
effects of geographic adjustment factors, 91–92
effects of Medicare’s national fee schedule, 126–127
expected outcomes of Phase I recommendations, 82–83
geographic distribution, 66, 67–74, 68f, 69f, 70f, 72f, 74f, 75f, 77f, 82
Medicare participation and, 6–7, 19
national targets, 117
need for government entity to oversee, 10–11, 118–119, 139–140
outcomes of programs and policies to improve, 7, 107–114, 136
policy considerations affecting, 117–118
practitioner population included in assessment of, 16, 17b
programs to encourage clinical practice in underserved areas, 96–100, 107–114
projections, 64, 66
quality of care and, 66–67, 136
recommendations for improving, 10–11, 139–141
research needs, 99–100, 113–114
scope of practice issues and, 8, 10, 81–82
strategies for improving, 8, 64, 65, 92
study goals, 2b, 14–15, 15b, 18, 19
telehealth credentialing, 80
HITECH Act, 104, 104n
Hospital Compare, 102
Hospital Consumer Assessment of Healthcare Providers and Systems, 100
Hospital Inpatient Quality Reporting Program, 100
Hospital readmissions, 78, 100–102
Hospital wage index
accuracy, 24
benefits index, 148–150, 149t
as budget-neutral in simulations, 24, 161–163
computation of, 32–33b, 155–158, 160–161
fixed-weight index, 147–148, 148f
function, 32b
hospitals with special payment status, 10, 30–31, 32t, 33t, 139
location-based adjustments for special groups of hospitals, 10
outcomes of simulations based on Phase I recommendations, 4, 19–20, 23–31, 26f, 28f, 34t, 44–47, 48–50, 136
in Phase I simulation methodology, 146
recommendations from Phase I report, 24, 25b, 26t
year-to-year changes, 34t
Household income, 39, 171t
I
Idaho, 101
Illinois, 101
Immigration law, 111–112
Inpatient Prospective Payment System
hospitals with special payment status, 30–31, 32t, 33t, 139
impact of Phase I recommendations, 25, 27, 28f, 163–167f
Medicare adjustments for hospitals in isolated areas, 94–95
International medical students, 111–112
J
J-1 waiver program, 111–112
L
Labor markets
computation of geographic practice cost indexes, 35b
computation of hospital wage index, 32–33b
definition, 16b
statewide versus nonstatewide payment localities, 37–38
See also Health workforce supply and distribution; Smoothing labor market borders and payment areas
Licensure, professional, 8, 64–65, 71, 81–82, 107, 138
Loan forgiveness programs, 107, 108, 110–111, 113–114, 119
Louisiana, 101
Low-volume hospitals, 10, 92, 95, 96, 139
Lugar hospitals, 30
M
Maine, 56
Massachusetts, 46, 47, 56
Medical home concept, 114
Medicare
chronic conditions among beneficiaries of, 6, 19, 76–77
consumer satisfaction, 59–62, 60t, 100
coverage, 1, 13, 56–57
current access to care for beneficiaries of, 5–6, 7, 53–54, 82, 91
current health care workforce, 64
current quality of care in, 58–63
current spending, 1, 13, 78
delivery system reforms to promote access and quality, 114–117
fee setting policies, 126–127
geographic distribution of beneficiaries, 6n
influence on health workforce supply and distribution, 114, 126, 136
Part B services, 42, 54, 56–57, 82, 97–98
policies to maintain access to care, 92–96, 93–94t, 119
practitioner population, 6–7, 19, 57
programs to improve quality of care, 119 100–104
projected growth, 81
recommendations for improving access to services, 9–10, 137–139
reimbursement for nonphysician health professionals, 117–118
reimbursement reforms to improve access and quality, 91, 131–132
shared savings program, 115
subsidization of graduate medical education, 127–129
supplemental coverage, 54
telehealth services coverage, 78t, 79–81
See also Simulation of Phase I recommendations
Medicare Advantage, 54n
Medicare Cost Reports, 32b
Medicare-dependent hospitals, 10, 31, 92, 95, 139
Medicare Improvements for Patients and Providers Act, 6, 102
Medicare Modernization Act, 95
Medicare Payment Advisory Commission (MedPAC), 53–54, 127
Medigap, 54n
Metropolitan and nonmetropolitan areas
access to care, 55–56, 82
determinants of practitioner location decisions, 104–107
effects of Medicare’s national fee schedule on physician location decisions, 127
in frontier states, 30
health workforce distribution, 64, 66, 67–69, 69f
methodology for analysis of payment rate mediation of quality of care, 175–178, 180t
outcomes of simulations based on Phase I recommendations, 4, 5, 27, 34–37, 38f, 39, 41–42, 44–47, 49, 50, 136, 163f, 165t, 167f, 169t, 170t
primary care billings, 127, 128f
quality of care variation between and within, 6, 63–64, 180t, 181t
statewide versus nonstatewide payment localities, 37
study goals, 2b, 15b, 18
workforce distribution and supply in, 6, 7, 15b
See also Rural areas
Micropolitan areas, 56, 63
Minnesota, 45, 56
N
National Health Care Workforce Commission, 10, 11, 139–140
National Health Disparities Report, 59
National Health Quality Report, 59
National Health Service Corps, 11, 108–110, 113, 127, 136, 140–141
National Healthcare Quality Report, 102
National Impact Assessment of Medicare Quality Measures, 103
National Institute for Minority Health and Health Disparities, 130
National Institutes of Health, 130
National Quality Strategy, 102–104
National Strategy for Quality Improvement in Health Care, 103
New England City and Town Areas, 146–147
New Hampshire, 73
New Jersey, 77–78, 101
North Dakota, 42, 43f
Nurse practitioners
current and projected supply, 66
in delivery system reforms to promote access and quality, 114, 115, 116
health care delivery role, 71, 84
Medicare payment policy, 117–118
minority population utilization of, 129
recommendations for scope of practice, 10, 138–139
scope of practice issues, 8, 10, 81–82, 83b
supply and geographic distribution, 71–73, 74f, 75f
training, 71
O
Ohio, 46
Oregon, 101
P
Patient Protection and Affordable Care Act. See Affordable Care Act
Payment policy
effectiveness of current programs to encourage practice in underserved areas, 107–114
effects on health care access and quality, 6, 8, 11, 18, 91
evidence of overpayment or underpayment, 23
to improve quality of care, 100–102, 116–117
influence on practitioner location decisions, 105–107
loan forgiveness programs, 107, 108, 110–111, 113–114
Medicare reimbursement reforms to improve access and quality, 131
Medicare’s fee setting policies, 126–127
methodology for analysis of payment rate mediation of quality of care, 175–178
programs to encourage clinical practice in underserved areas, 3–4, 96–98
recommendations from Phase I report, 24, 25b, 26t
reimbursement for nonphysician health professionals, 117–118
study goals, 2b, 8, 15b, 18, 19
value-based purchasing, 116–117, 131
See also Geographic adjustment, generally; Geographic practice cost indexes; Hospital wage index; Primary care bonus payment program
Pennsylvania, 47
Phase I. See Geographic Adjustment in Medicare Payment: Phase I: Improving Accuracy
Physician assistants, 66, 71, 73–74, 76f, 77f, 82, 114, 116, 117–118, 129
Physician Compare, 102
Physician education and training
influence on practice location decisions, 107–108, 112–113
shortcomings of data on, 118
subsidization of graduate medical education, 112–113, 126, 127–129
Physician Quality Reporting System, 102
Pioneer accountable care organizations, 115
Policy adjustments
cross-subsidization, 23, 23n
definition, 16b
recommendations from Phase I report, 24
rural floor adjustments as, 30
in simulations of Phase I recommendations, 4, 20, 24, 48
Population health
effect of provider payment policies on, 92
racial and ethnic disparities, 126, 129–130
study goals, 2b, 14–15, 15b
Premier Hospital Quality Incentive Program, 103b
Primary care
in community health centers, 96–97
coordination of care in, 117
definition, 17, 17b, 53
influences on physicians’ career decisions, 107–108
outcomes of Phase I simulations by county percent of primary care relative value units, 172t
physician caseloads, 99
physician supply and geographic distribution, 7, 58f, 67–69, 70f, 73t, 99
practitioner earnings in, 106b
recommendations for improving access to, 9–10, 137–139
reimbursement for nonphysician health professionals, 117–118
scope of practice regulations, 10, 81–82, 84, 138–139
in a well-functioning health care system, 52–53, 84
Primary care bonus payment program
bonus, 42, 97–98
disbursement methodology, 39–41
disbursements to date, 98
effectiveness, 98, 119, 127
eligibility of health professionals for, 3–4, 16, 17, 98
geographic distribution, 40–42
to offset geographic practice cost index reductions, 42–43
recommendations for, 9, 137
See also Health Professional Shortage Areas
Public Health Service Act, 11, 107n, 127, 140
Puerto Rico, 47, 48b, 49b
Q
Quality of care
access to care and, 59
in community health centers, 96–97
current data collection and dissemination, 6
current system performance, 6, 58–64, 60t, 82
definition and measures of, 17b, 19, 20t, 51–52, 52t, 59–60, 100
delivery system reforms to improve, 114–117
determinants of, 132
effectiveness of incentive payment programs, 103b, 119
effects of geographic adjustment, 2–3, 6, 7, 14, 51, 61–62, 82–83, 84, 104, 119, 125, 136
expected outcomes of Phase I recommendations, 2–3, 6, 61–62, 125
in Health Professional Shortage Areas, 179t, 181t
health workforce supply and, 66–67, 136
hospital readmission rates, 78, 100–102
methodology for analysis of payment rate effects, 175–178
in metropolitan and nonmetropolitan areas, 6, 63–64, 180t, 181t
National Quality Strategy, 102–104
physician payment policy to improve, 102
regional variation in, 62–63
strategies for improving, 8, 100–104
study goals, 2b, 14–15, 15b, 51
underserved populations, 63, 82
value-based purchasing, 116–117
R
Racial and ethnic minorities
access to care, 2–3, 6, 53, 55–56, 57–58, 82, 83, 129
hospital readmission rates, 101–102
outcomes of Phase I recommendations for, 2–3, 129, 136–137, 171t
population health research, 126, 129–130
quality of care received by, 63, 82, 83
strategies to reduce health care disparities, 129–130, 130b
study goals, 2–3
utilization of nonphysician health professionals, 129
Recommendations
commuter smoothing, 29b
from Geographic Adjustment in Medicare Payment: Phase I, 1, 2–5, 13, 24, 25b, 135
hospitals with special payment status, 10, 139
to improve access to care, 9–10, 11, 137–139, 140–141
to improve workforce supply and distribution, 10–11, 139–140
See also Simulation of Phase I recommendations
Recruitment and retention of health care workforce
future challenges, 64
study goals, 2b, 15b
in underserved areas, effectiveness of programs to improve, 11, 107–114, 140–141
Registered nurses, 70, 72f
Relative value units, 4, 25–26, 35b, 127, 128f, 150
Rent costs, 24n, 35b, 145
Resource-based Relative Value Scale, 127
Rhode Island, 56
Rural areas
determinants of practitioner location decisions, 104–105, 107–108, 112
distribution of Medicare beneficiaries, 18n
health workforce supply, 64, 67, 68–69, 71, 73
hospitals with special payment status, 10, 30–31, 33t, 139
Medicare payment policies for hospitals serving, 92–94
outcomes of programs to encourage practice in, 107–114
outcomes of simulations based on Phase I recommendations, 4–5, 27, 38, 38f, 39, 132, 171t
population distribution, 68
recommendations for improving access to care in, 9–10, 137–139
scope of practice issues for health care workforce in, 82
See also Metropolitan and nonmetropolitan areas
Rural floor adjustment, 4, 23n, 29–30, 33b, 45, 46–47, 49
Rural Health Care Pilot Program, 78–79
Rural referral centers, 4, 31, 49, 92, 95, 96
recommendations for, 10, 139
Rural–Urban Continuum Code, 39, 60–61, 62, 153, 176, 177, 178, 180t, 181t, 182t
S
Scope of practice issues, 8, 81–82, 83b, 138–139
Screening, 77–78
Shared savings, 115, 131
Shortage areas. See Health Professional Shortage Areas
Simulation of Phase I recommendations
access to care, 2–3, 6, 82–83, 136–137
aggregate geographic adjustment factors changes, 168t
budget neutrality in, 24, 161–163, 162t
distribution of effects across payment areas, 26–27
effects in counties by percent of primary care relative value units, 172t
examples of provider impact, 44–47
hospital adjustment status effects, 166t
hospital payment computations, 146, 155–158, 160–161
hospital payment outcomes, 4, 19–20, 23–31, 26f, 28f, 48–50, 125, 136
hospital size effects, 167t
hospitals with special payment status, 30–31, 32t, 33t
impact of Bureau of Labor Statistics data, 4, 27, 28f, 30–31, 49
Inpatient Prospective Payment System outcomes, 25, 27, 28f, 163–167f
key findings, 48–50
mapping of Health Professional Shortage Areas, 152–155, 156f, 156t, 157t
methodology, 23, 145–163
outcomes by household income, 171t
outcomes for frontier states, 4, 5, 38–39, 132
outcomes for racial and ethnic minorities, 2–3, 129, 136–137, 171t
outcomes in metropolitan and nonmetropolitan areas, 4–5, 27, 34–37, 38f, 39, 49, 50, 132, 136, 163f, 165t, 167f
outcomes in shortage areas, 2–4, 5, 9, 20, 39–44, 41t, 50, 62, 125–126, 132, 137
physician payment computations, 146, 159–160, 161
physician payment outcomes, 4–5, 23–27, 26f, 31–47, 36f, 50, 61–62, 125–126, 136, 167f, 169–171t, 172t
policy adjustments in, 4, 20, 24, 48
quality assurance and quality control in preparation of, 183–186, 186t
quality of care outcomes, 125
rural floor adjustments in, 4, 29–30, 46–47
scope of analysis, 24
smoothing labor market borders and payment areas in, 4–5, 27, 45–46, 47, 49, 50, 150–152, 151t, 152t, 153f, 154t
use of core-based statistical areas, 4, 34, 37–38, 45–46, 50
Smoothing labor market borders and payment areas
computation of geographic practice cost indexes, 34n, 37, 37n
computation of hospital wage index, 33b
methodology, 29b, 150–152, 151t, 152t, 153f, 154t, 157
outcomes of simulations based on Phase I recommendations, 4–5, 27–28, 37, 37n, 45–46, 47, 49, 50
recommendations, 29b
Social Security Act, 2b, 15b, 97
Sole community hospitals, 10, 31, 92, 94–95, 96, 139
Specialty medicine, access to
geographic variation in, 53–54, 66, 67, 99, 105, 114
for minority populations, 58, 82, 84
nurse practitioners and physician assistants and, 71, 72, 84
practitioner career decisions and, 104, 106b, 107–108, 112
recommendations for improving, 9–10, 137–138
telemedicine and, 75, 76, 84
trends, 69, 105
Subsidization of graduate medical education, 112–113, 126, 127–129
Surgeons, 69, 71f, 84, 98
T
Telehealth technologies
credentialing of providers for, 80
current implementation, 8, 9–10, 74–75, 138
definition, 8, 9, 138
effectiveness, 8, 77–78
future prospects, 80–81
infrastructure, 78–79
Medicare payment provisions, 79–80, 81
recommendations for, 9–10, 84, 137–138
Transitional care, 114, 117
U
Underserved areas
influences on physicians’ career decisions, 107–108, 112–113
outcomes of programs to encourage clinical practice in, 7, 11, 108–114, 140–141
programs to encourage clinical practice in, 96–100
recommendations for improving access to care in, 9–10, 11, 137–138, 140–141
study goals, 135
underserved populations versus, 16–17
See also Health Professional Shortage Areas
Utah, 101
V
Value-based purchasing, 116–117, 131
Virginia, 47
W
Washington state, 74
West Virginia, 45