3

Evidence of Geographic Variation in Access,
Quality, and Workforce Distribution

In its Phase I report, the Committee on Geographic Adjustment in Medicare Payment (the committee) made several recommendations about changing payment policy to improve the accuracy of the geographic adjustment factors that are used to adjust payments to providers. During Phase II, in keeping with the statement of task, the committee focused on the potential effects of the proposed payment changes on Medicare beneficiaries’ access to high-quality health care in designated shortage areas as a way to reflect defined geographic areas whose residents may be particularly likely to have problems accessing care.

This chapter describes the evidence of geographic differences in access to and quality of care provided to Medicare beneficiaries. It presents an original analysis of data from the Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey suggesting that the effects of geographic adjustment are not associated with consumer-reported performance relating to access and timeliness of care or quality of care in different geographic areas. The chapter then describes the geographic distribution of the workforce that provides health care services to beneficiaries, including physicians, nurse practitioners, and physician assistants. It next discusses some new opportunities to improve access through telehealth and changes in scope of practice, which help to increase productivity and make better use of health professionals who are already part of the workforce. The chapter concludes with the committee’s findings about what the evidence shows about access and quality of care.

In reviewing the evidence of geographic differences in access and quality of care for Medicare beneficiaries, the committee adopted accepted definitions of access and quality as defined by previous Institute of Medicine (IOM) committees (see Box 1-1). The committee recognized that access and quality are closely related concepts, and that the early quality measurement efforts relied on the Donabedian (1966) framework of structure (e.g., organizational factors, practice setting, staffing), process (the delivery of care), and outcomes (e.g., changes in health status) (see Table 3-1 for relevant measures from a Donabedian framework). Quality measurement efforts have now evolved into a highly differentiated set of more than 450 performance



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3 Evidence of Geographic Variation in Access, Quality, and Workforce Distribution I n its Phase I report, the Committee on Geographic Adjustment in Medicare Payment (the committee) made several recommendations about changing payment policy to improve the accuracy of the geographic adjustment factors that are used to adjust payments to providers. During Phase II, in keeping with the statement of task, the committee focused on the potential effects of the proposed payment changes on Medicare beneficiaries' access to high-quality health care in designated shortage areas as a way to reflect defined geographic areas whose residents may be particularly likely to have problems accessing care. This chapter describes the evidence of geographic differences in access to and quality of care provided to Medicare beneficiaries. It presents an original analysis of data from the Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey suggesting that the effects of geographic adjustment are not associated with consumer-reported performance relating to access and timeliness of care or quality of care in different geographic areas. The chapter then describes the geographic distribution of the workforce that provides health care services to beneficiaries, including physicians, nurse practitioners, and physician assistants. It next dis- cusses some new opportunities to improve access through telehealth and changes in scope of practice, which help to increase productivity and make better use of health professionals who are already part of the workforce. The chapter concludes with the committee's findings about what the evidence shows about access and quality of care. In reviewing the evidence of geographic differences in access and quality of care for Medi- care beneficiaries, the committee adopted accepted definitions of access and quality as defined by previous Institute of Medicine (IOM) committees (see Box 1-1). The committee recognized that access and quality are closely related concepts, and that the early quality measurement efforts relied on the Donabedian (1966) framework of structure (e.g., organizational factors, practice setting, staffing), process (the delivery of care), and outcomes (e.g., changes in health status) (see Table 3-1 for relevant measures from a Donabedian framework). Quality measure- ment efforts have now evolved into a highly differentiated set of more than 450 performance 51

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52 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT TABLE 3-1 Sample Measures Included in the Evidence Review Structure Process Outcome Access Supply and N o. of practitioners per W aiting time to get an Population health distribution 10,000 population appointment with a new practitioner Geographic T ravel time to nearest practitioner Availability of transportation Affordability C opayment Seek care on timely basis Cost of transportation Cost of time off from work Quality Access H ave a usual source of W aiting time in office care before appointment Organizational N urse-to-patient ratio in hospital Leadership P resence of infection control program Adherence to clinical guidelines Infrastructure M eaningful use of Clinical decision support electronic health record Videoconferencing Clinical P ercent of infections H ospital readmission Percent of post-MI Survival 1 year post-MI patients who leave with prescription for beta blocker Patient Get care when needed R ating of care experience Rating of practitioner Rating of health status NOTE: MI = myocardial infarction. SOURCE: Developed by the committee for this report. measures that are available to the public in a clearinghouse whose clinical quality measures include process, access, outcome, structure, and patient experience (AHRQ, 2012a). 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. Those studies are summa- rized in the next section. GEOGRAPHIC VARIATION IN ACCESS TO HEALTH CARE In the committee's view, a well-functioning health care system has a foundation of primary care and includes the full continuum of care, from primary to secondary and tertiary care.

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EVIDENCE OF GEOGRAPHIC VARIATION 53 Primary care is defined by a 1996 IOM study committee as "the provision of integrated, acces- sible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community" (IOM, 1996a, p. 1). This definition describes primary care as neither a discipline nor a specialty. It cannot be understood as a list of problems, tasks, or services or by the credentials of the person providing the services. This function provides and integrates services for most health care problems, in the context in which the user of health care services lives (Green, 2004), and the health outcomes of many people can benefit from primary care management. Respondents from the 20002005 Medical Expenditures Panel Survey linked to the National Death Index through 2006 showed a reduction in mortality among those who reported more of three core attributes (comprehen- siveness, patient-centeredness, and enhanced access) of primary care at their source of care (Jerant et al., 2012). Racial/ethnic minorities, poorer and less-educated persons, individuals without private insurance, healthier persons, and residents of regions other than the Northeast were reported to have less access to primary care attributes than others (Jerant et al., 2012). The following sections review what is known about access to primary and specialty care and the quality of care, with an emphasis on underserved areas and racial and ethnic minorities. Access to Health Care Generally speaking, the majority of Medicare beneficiaries have good access to care (MedPAC, 2011), when access is defined as services that are readily available and that yield the most favorable outcomes possible (AHRQ, 2010a; IOM, 2010). Market-specific data are limited, but the 2007 National Ambulatory Medical Care Survey found that just over 90 percent of primary care physicians and 94 percent of specialists with at least 10 percent of their practice revenue coming from Medicare were accepting new Medicare patients1 (MedPAC, 2009). The 2011 National Health Interview Survey found that more than 95 percent of Americans aged 65 and older said they had a usual place to go for medical care, which is one of the most frequently used measures of access to care (CDC and NCHS, 2011). While these findings are generally encouraging, they indicate that significant numbers of beneficiaries still report barriers to accessing care in their own local geographic areas as mea- sured by unwanted delays in getting appointments or in finding a new primary care physician or specialist. A 2003 Medicare Payment Advisory Commission (MedPAC) survey of beneficiaries targeted 11 sites with a history of access problems. Although the survey was not nationally representative, and thus may have been biased, it found that it was harder for beneficiaries to get an appointment with a physician if they were transitioning into Medicare or new to a geo- graphic area, in poor or fair health, had functional limitations, low incomes, and were without supplemental insurance (Lake et al., 2004). The fall 2011 MedPAC beneficiary survey found that 74 percent of beneficiaries age 65 and older who needed an appointment for routine care and 83 percent of those who needed an appointment with a specialist for illness or injury never had 1 The National Ambulatory Medical Care Survey contacts randomly selected nonfederally employed physicians from 15 specialty groups who are involved in direct office-based patient care to ask about ambulatory care. It excludes radi- ologists, pathologists, and anesthesiologists. Primary care includes general/family practice and internal medicine, and specialties included obstetrics/gynecology, cardiology, ophthalmology, general surgery, orthopedic surgery, psychiatry, and others (NCHS Data Brief No. 41, August 2010).

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54 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT to wait longer than they wanted (MedPAC, 2012a,b). Only a small proportion of those surveyed were looking for a new physician (6 percent for primary care and 14 percent for a new specialist). Among the 6 percent of Medicare beneficiaries age 65 and older seeking a new primary care physician, the share of beneficiaries who reported "a big problem" almost doubled in 2011 compared to the 2 previous years (23 percent in 2011 compared to 12 percent in 2010 and 2009); this represented about 1.2 and 0.08 percent of these beneficiaries, respectively (MedPAC 2012b). In comparison, among the 14 percent of beneficiaries age 65 and older seeking a new specialist, the share of beneficiaries who had a "big problem" finding a new specialist was about 7 percent in 2011, compared to 5 percent in the 2 previous years, which represented 1.0 and 0.7 percent of these beneficiaries, respectively. Out-of-pocket costs can contribute to access problems for beneficiaries. Most Medicare beneficiaries have premium-free coverage for inpatient care in hospitals, skilled nursing facili- ties, hospice, and home care under Part A, which requires deductibles and copayments for the services used. Beneficiaries who also wish coverage for Part B services, which include physician, laboratory, and home health services, pay an income-related premium for coverage, and deduct- ibles and copayments for services (CMS, 2012b). In 2008, 90 percent of beneficiaries reported having supplemental coverage through employer-sponsored plans, Medicare Advantage2 (Part C), Medigap3 policies, and Medicaid (KFF, 2010a). Beneficiaries who reported annual incomes between $10,000 and $20,000, being in poor health, and being nonelderly disabled people are more likely to lack supplemental coverage (KFF, 2010a). However, beneficiaries with only Medicare coverage are just slightly (3.4 percent) less likely to have a consistent source of care than those who have additional private insurance, according to 2008 data from the National Health Interview Survey (CDC and NCHS, 2011). In sum, the majority of beneficiaries have a usual source of care and are able to see practitio- ners when they choose. As the next sections show, where access problems exist, they are gener- ally due to shortages of health professionals in a geographic area or region; specific shortages of local providers who accept Medicare, which may be temporary or persistent; or individual characteristics of beneficiaries, such as the inability to make copayments, lack of transportation, cultural health beliefs, personal preferences, or being members of racial and ethnic minorities. Geographic Differences in Access Supply of Health Professionals An adequate supply of health professionals, a clinically appropriate mix of practitioners, and balanced geographic distribution of these practitioners are necessary to deliver health care to Medicare beneficiaries. The committee reviewed available evidence and had multiple discussions about the degree to which shortages of practitioners in certain geographic areas are due to shortages in the total numbers of clinicians, or whether location decisions are more influenced by factors such as population density that is sufficient to support a medical practice, the prac- 2 Medicare Advantage is health maintenance organization (HMO) or preferred provider organization (PPO)-style health care; includes Parts A and B; and may include extra coverage for vision, hearing, dental, and/or health and wellness programs (Medicare.gov/navigation/medicare-basics/medicare-benefits/part-c.aspx). Premiums and out-of- pocket costs may vary. 3 Medigap policies help pay some of the "gaps" in original Medicare coverage, including copayments and deductibles (CMS, 2012c; Choosing a Medigap Policy, www.medicare.gov/publications/pubs/pdf/02110.pdf).

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EVIDENCE OF GEOGRAPHIC VARIATION 55 titioners' preferences about quality of life, and experience training in a medically underserved metropolitan or nonmetropolitan area. Chapter 4 reviews literature on location decisions and includes a review of the programs and strategies that have been used to recruit practitioners to shortage areas. Medicare is the largest single source of health coverage in the United States, but because it is part of a multipayer system, local market factors such as prevailing payment rates, supply of practitioners, and percentage of uninsured in the local population may play a significant role in beneficiary access at the local level. In other words, if a local area has a large number of medically underserved individuals, Medicare beneficiaries are also likely to have more problems accessing care. Health Professional Shortage Areas (HPSAs) The committee used Health Professional Shortage Area (HPSA) designations to identify underserved areas for its payment simulations, as reported in Chapter 2. An HPSA is an admin- istrative designation by the Health Resources and Services Administration (HRSA) that identi- fies areas with a low or insufficient primary care workforce (see Box 3-1) (HRSA, 2012). HPSA designations guide the payment policies behind bonus payments for primary care and general surgery and the workforce policies that determine the placements of participants in the National Health Service Corps and other loan repayment programs described in Chapter 4. As of February 29, 2012, nearly 60 million Americans--approximately 1 out of every 5--live in one of 5,816 designated primary care HPSAs (HRSA, 2012). Although the exact number of HPSAs fluctuates, approximately two-thirds of the primary care HPSAs are in nonmetropolitan areas, and one-third are in metropolitan areas (see Figures 3-1 and 3-2). As reported in Chapter 2, the committee's recommendations have little effects on the pay- ments to hospitals in HPSAs and a downward effect of 3 percent or less on the payments to practitioners. Access in Metropolitan and Nonmetropolitan Areas Broadly speaking, Medicare beneficiaries in nonmetropolitan and metropolitan areas have similar levels of access to fee-for-service care (AHRQ, 2010b; MedPAC, 2011). Compared to beneficiaries in metropolitan areas, those in nonmetropolitan areas often travel long distances to see practitioners because they tend to live further away from a health care facility (Arcury et al., 2005). However, beneficiaries in metropolitan areas who rely on public transportation may also need to spend a significant amount of time traveling to appointments even when the geographic distances are comparatively shorter. For low-income beneficiaries, particularly those who also have disabilities or mobility challenges, the burden associated with travel may present ongoing challenges for achieving and maintaining access to care. The impact of travel time on access to care, and how many beneficiaries will miss appointments or forego care because of these challenges, is not well studied and needs further attention (Chan et al., 2006). Metropolitan areas with greater population density are more likely to have racially, ethni- cally, and economically diverse populations and neighborhoods (Commonwealth Fund, 2012). Thus, metropolitan beneficiaries are disproportionately more likely to be members of racial and ethnic minorities (Balfour and Kaplan, 2002; Fitzpatrick et al., 2004). Compared with residents of large city suburbs, residents of large inner cities had worse access for about 35 percent of

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56 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT BOX 3-1 Health Professional Shortage Areas (HPSAs): History and Methodology HPSAs (originally referred to as the Health Manpower Shortage Area) were developed in the 1970s to identify geographic areas eligible to hire physicians under the National Health Service Corps program. Legislation in 1976 allowed special populations and facilities to be designated as HPSAs in addition to geographic areas. HRSA develops the shortage designation criteria, which may apply to shortages of pri- mary medical care, dental, or mental health providers. By statute, HPSAs are determined by identifying areas where the delivery of primary care would be "rational, have a shortage of primary care professionals, and where primary care professionals surrounding these areas are overutilized, excessively distant, or inaccessible to the population of the area under consid- eration. A shortage is when an area has either a population-to-physician ratio greater than 3,500 people per 1 full-time physician*; or a population-to-physician ratio fewer than 3,000 people per 1 physician* and there is an unusually high need for primary care services, or an insufficient capacity of existing primary care providers." The HPSA designation has not been substantially changed since its inception. HRSA pre- sented two proposed rule changes that would modify the process, but they were withdrawn after substantial public input. The Affordable Care Act charged a Negotiated Rulemaking Committee with developing a revision, but a consensus for change could not be reached. The Secretary of the Department of Health and Human Services may, however, take the commit- tee's recommendations and issue a proposed rule. Because an agency or organization must apply for HPSA status, many areas with primary care shortages are not designated as HPSAs. A public or private nonprofit organization must first apply to HRSA in order for a county or group of counties to be considered a HPSA. Therefore, many counties with a less than adequate number of primary care professionals may not be designated as a HPSA, if there is insufficient political or administrative power or agreement to do so. *When calculating population to physician ratios, physicians--who are practicing within a HPSA because of programs based on HPSA designations--are excluded. SOURCES: 42 CFR Part 5, Appendix A; also see Shortage Designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations (http://bhpr.hrsa.gov/shortage) (HRSA, 2012). the 22 measures included in a core set of access measures used by the Department of Health and Human Services (HHS). Residents of micropolitan areas (counties with an urban cluster of 10,000 to 50,000 inhabitants) had worse access for 50 percent of access measures compared with residents of large fringe metropolitan areas (outlying counties in metropolitan areas of more than 1 million inhabitants) (AHRQ, 2010b). Medicare Participation Rates Centers for Medicare & Medicaid Services (CMS) data from 2009 show that the national average participation rate for Medicare Part B is 96 percent and varies from a high of 99 percent in Maine, Massachusetts, and Rhode Island to a low of 82 percent in Minnesota (KFF, 2010c).

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EVIDENCE OF GEOGRAPHIC VARIATION 57 No data Non-HPSA Partial HPSA Full HPSA State FIGURE 3-1 County designations for nonmetropolitan primary care service shortage areas. NOTE: HPSA = Health Professional Shortage Area. SOURCE: ARF, 2009. Figure 3-1.eps An analysis of physician4 responses to the 2008 Health Tracking Physician Survey by the Center for Studying Health System Change reported that 11 percent of metropolitan and 8 percent of nonmetropolitan physicians were not accepting any new Medicare patients (MacKinney et al., 2011). A University of Alaska survey of primary care physicians5 found that almost all physicians in smaller communities were taking new Medicare patients, but that 1 out of 10 primary care physicians had opted out of Medicare, and most of them were in Anchorage, an urban area where private payments are significantly higher (Frazier and Foster, 2009). This lower participa- tion rate in turn creates access problems for beneficiaries who often have a longer wait time before an appointment. Accordingly, MedPAC will continue to monitor the areas in which access disparities have been identified in its previous surveys of beneficiaries. Access for Racial and Ethnic Minorities Racial and ethnic minorities consistently face more barriers when trying to access care (AHRQ, 2010b). In its 2011 physician access survey, MedPAC found that members of racial and 4 Responses were from 1,937 physicians from family medicine, general practice, general internal medicine, obstetrics/ gynecology, geriatric medicine, and general surgery. 5 A 2008 survey identified all licensed primary care physicians who could see the general population of Medicare patients in Alaska and reached 85 percent of them for interviews (N = 229). Those who were not taking new Medicare patients in 2008 were followed up with another survey in 2009.

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58 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT No data Non-HPSA Partial HPSA Full HPSA State FIGURE 3-2 HPSA county designations for metropolitan primary care service shortage areas. Figure NOTE: HPSA = Health Professional Shortage Area. 3-2.eps SOURCE: ARF, 2009; HRSA Area Resource File and CMS Hospital Labor Markets. ethnic minorities experienced more access problems than nonminority beneficiaries whether they had Medicare coverage or were privately insured. The same survey also found that the share of minority beneficiaries who reported problems finding a specialist had increased since its previous survey (MedPAC, 2012a). In the future, MedPAC plans to add survey questions to help improve understanding of the causes of these disparities and to identify possible policy options for improvement. The MedPAC findings of access disparities for beneficiaries mirror the problems in the larger population, which have been documented since 2003 in a series of reports by the Agency for Healthcare Research and Quality (AHRQ) (2010a,b). Disparities in access to care for Medicare beneficiaries who are members of racial and ethnic minorities cannot be addressed by the Medicare program alone; a coordinated national strategy will be required, and such a strategy is discussed in Chapter 5. GEOGRAPHIC VARIATION IN QUALITY OF CARE One of the primary goals of the Medicare program is to ensure that beneficiaries are able to receive medically appropriate, high-quality care when they need it. The quality of care for fee-for-service Medicare beneficiaries has been improving slowly over time for multiple condi- tions in hospital and outpatient settings (AHRQ, 2010a; Jencks et al., 2003). HHS measures access to care in terms of the availability of health coverage; availability of

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EVIDENCE OF GEOGRAPHIC VARIATION 59 a usual source of care; patient assessments of how easy or difficult it is to gain access to health care; and the successful receipt of services (AHRQ, 2010b). To measure quality, HHS uses a core set of evidence-based quality measures6 to make standardized comparisons of the quality of care for different groups and regions (AHRQ, 2010a,b). Quality measures are typically classified as either process or outcome measures. Process measures may be derived from administrative (e.g., claims), clinical, or survey data that assess performance in the delivery of preventive ser- vices, acute care, and chronic disease management (e.g., time in waiting room, availability of medication history at time of the appointment) (AHRQ, 2010a). Outcome measures are often disease specific and include clinical outcomes, such as changes in health status after treatment, as well as patient satisfaction with practitioners and the care experience. The Relationship of Access and Quality of Care Access and quality of care are closely related, in that better access to care and higher rates of insurance coverage are closely associated with higher quality of care (Commonwealth Fund, 2012). In geographic areas where more people have health coverage and are better able to access health care, they are also more likely to have a usual source of primary care and to receive higher-quality hospital care, as reflected by receiving more of the recommended care processes and reporting better patient care experiences during hospitalization (Commonwealth Fund, 2012). Areas with very high poverty rates tend to have more people who are uninsured, who go without care because of cost, lack a regular source of primary care, and have worse health outcomes (Commonwealth Fund, 2012). Disparities in access to and quality of care have not improved over several years of track- ing and reporting by HHS. They continue to be a national policy priority (AHRQ, 2010a), as discussed in Chapter 5 of this report. In 2010, an IOM committee assessing the National Health Disparities Report (NHDR) and the National Health Quality Report (NHQR) recommended a har- monization and expansion of both reports (IOM, 2010). The NHDR will include the dimensions of quality covered by the NHQR, and the measurement of quality in both reports will consider care coordination and health systems infrastructure capabilities as "foundational components" that must be in place before any of the objectives in other quality areas can be achieved (IOM, 2010). Chapter 4 includes sections on current efforts for public reporting of performance by hospitals and clinical practitioners. Geographic Payment Factors and Beneficiary- Reported Quality in Fee-for-Service Medicare The committee recognized there is considerable concern, reflected in stakeholder testimony at public sessions,7 that variations in health care quality and access across geographic areas could be influenced by variations in payment rates. In particular, there was concern that lower payment rates in rural and underserved areas could exacerbate quality and access issues in these areas (see Appendix E). Little published research was found that established an empirical foundation for evaluating this concern. Therefore, the committee conducted an analysis of data collected as part of the 2010 CAHPS survey of Medicare beneficiaries in the traditional Medicare (fee-for-service) sector (see Table 3-2 for a description of CAHPS items used). CAHPS is widely viewed as a good data source 6 The core set of quality measures is available at http://www.ahrq.gov/qual/nhdr10/Core.htm. 7 See IOM, 2011, Chapter 1.

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60 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT for ambulatory (mainly primary) care, and the committee found CAHPS data to be a reasonable choice for the modeling of quality associations with payment factors for physician offices. While a different analysis might have been conducted using hospital quality data and payment factors in a parallel analysis, the committee lacked the resources to do both. The committee focused on CAHPS measures of access/timeliness of care, experiences with care, and clinical quality (measured by immunizations). The measures were controlled for education, general and mental health status, age, Medicaid dual eligibility, low-income supplement eligibility, and assistance by a proxy in completing the CAHPS questionnaire. The CAHPS measures were supplemented with five clinical measures following specifications of the Health Plan Employer Data and Information System, constructed from a 20 percent sample of fee-for-service Medicare claims from 2009 for breast cancer screening and recommended test- ing for cardiac patients and diabetics. Rurality was measured by the RuralUrban Continuum TABLE 3-2 Description of CAHPS Items, Number of Responses, and Rate of "Top Box" (Most Favorable) Responses Number of Overall Measure Responses Rate Item Text or Description Have personal 46,505 93.1 A personal doctor is the one you would see if you need a checkup, doctor want advice about a health problem, or get sick or hurt. Do you have a personal doctor? Timely routine 37,695 62.3 In the last 6 months, not counting the times you needed care right care away, how often did you get an appointment for your health care at a doctor's office or clinic as soon as you thought you needed? Timely care in 15,349 70.7 In the last 6 months, when you needed care right away, how often illness did you get care as soon as you thought you needed? Wait <15 39,447 59.0 Wait time includes time spent in the waiting room and exam room. minutes In the last 6 months, how often did you see the person you came to see within 15 minutes of your appointment time? Easy specialist 26,682 62.4 In the last 6 months, how often was it easy to get appointments with appointment specialists? Rating of care 39,417 39.0 Using any number from 0 to 10, where 0 is the worst health care overall possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 6 months? Rating of 36,309 51.0 Using any number from 0 to 10, where 0 is the worst personal doctor doctor possible and 10 is the best personal doctor possible, what number would you use to rate your personal doctor? Doctor 36,087 59.2 [Composite of four items] In the last 6 months, how often did communication your personal doctor explain things in a way that was easy to understand?/ listen carefully to you?/ show respect for what you had to say?/ spend enough time with you? Get needed 26,617 70.6 In the last 6 months, how often was it easy to get the care, tests, or care treatment you thought you needed through Medicare? Influenza 46,624 68.2 Have you had a flu shot since September 1, 2009? immunization Pneumovax 44,054 69.1 Have you ever had a pneumonia shot? This shot is usually given only immunization once or twice in a person's lifetime and is different from the flu shot. It is also called the pneumococcal vaccine. NOTE: CAHPS = Consumer Assessment of Healthcare Providers and Systems. SOURCE: A. Zaslavsky, developed for this report.

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EVIDENCE OF GEOGRAPHIC VARIATION 61 Code (RUCC), while HPSA designations, grouped by county percentages as in the Chapter 2 payment simulations, were used to identify areas with possibly inadequate supply of health care providers. This section summarizes the findings, and details of the analysis are provided in Appendix C of this report. Do Medicare CAHPS Data Identify Access Issues and Quality Issues Related to Rurality of a County and/or the County's HPSA Status? The data do suggest some differences, with metropolitan areas doing better on measures of timeliness of access, on immunizations, and on some of the screening/testing measures, and nonmetropolitan areas scoring higher on communication with doctors and overall satisfaction with physicians. Variations related to HPSA status are weaker, but when significant they are generally consistent with declining quality as the percent of a county designated as a HPSA area increases (with exceptions in the 100 percent HPSA counties). Are Payment Factors Associated with Beneficiary-Reported Measures of Access to and Quality of Care? The associations of payment factors with beneficiary reports are statistically significant, espe- cially as reflected in the physician work geographical practice cost index (GPCI). However, these differences do not support concerns from several stakeholders expressed in Phase I testimony that smaller geographic payment adjustments are associated with shortages or lower-quality services. If anything, the results show the opposite to be the case, as higher payment factors are associated with poorer beneficiary-reported quality. To What Extent Do Variations in Geographic Payments Explain Variations in Access and Quality by Rurality and/or HPSA Status? No evidence of this was found in this analysis of the CAHPS data. Introducing either the GPCI or the physician practice geographical adjustment factor (GAF) measure as an explana- tory variable had almost no effect on estimated access and quality differences along the RUCC or HPSA coverage dimensions. Would Use of the New Adjustment Factor Methodologies Proposed in the Committee's First Report Increase or Decrease Payments in Areas with Generally Better or Worse Current Quality of Care, as Reflected in CAHPS Survey Responses? The evidence on this point is mixed. One reason for this is that, while the switch to Con- solidated Metropolitan Statistical Areas instead of whole states (as recommended by the com- mittee) would tend to reduce payments to nonmetropolitan areas, these areas score better on some CAHPS measures and worse on others. While this analysis of CAHPS data contributes to the sparse existing literature on the rela- tionship between levels of payment and geographic variation in quality, the findings should be viewed only as suggestive, for several reasons. For example, the CMS's GAF and GPCI are defined for only 89 payment areas, which implies that each area is a state or a large and pos-

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80 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT in hospitals or skilled nursing facilities, office, or other outpatient visits; certain patient educa- tional services (including kidney disease management and diabetes self-management); and a limited number of other services. Payment for asynchronous "store and forward" services is provided only in federal telehealth demonstration projects in Alaska and Hawaii and is otherwise not reimbursed (CMS, 2012a). Under current payment provisions, originating sites include the office of an eligible practi- tioner, hospitals, rural health clinics, federally qualified health centers, hospital-based or critical access hospital-based renal dialysis centers, skilled nursing facilities, and community mental health centers. Originating sites are also paid a facility fee, which is separately billable under Part B. Services provided in other locations, including home health and hospice settings, are not eligible for reimbursement. Credentialing of Health Care Providers In May 2011, CMS reduced a significant barrier to providing telehealth services related to the credentialing of the practitioners by allowing the originating site's credentials to be rec- ognized by the receiving site. Previously, CMS regulations had required that the facility receiv- ing the telehealth services follow the same credentialing procedures as it would with its local practitioners. This was not only duplicative, but also burdensome on small facilities. These new CMS regulations are expected to expedite approvals of practitioners and reduce expensive and often cumbersome credentialing processes. Conflicting scope-of-practice requirements in different states have also made credentialing difficult for some clinicians who were providing telehealth services to out-of-state facilities. The new requirements simplify the process by allowing the receiving hospitals and other facilities to rely on the credentialing and privileging decisions of other institutions. This change was described by CMS administrator Donald M. Berwick as "an innovative practice in delivering care to all patients, especially those in rural or remote parts of the country" (CMS Office of Public Affairs, 2011). Expanding Opportunities in Telehealth Although it is beyond the statement of task for this committee to identify best practices in telehealth, or to detail recent changes in state laws, opportunities clearly exist for expanding the use of telehealth technologies to improve access and quality of care for beneficiaries in settings and locations where services are needed. For example, as mentioned above, reimbursement for asynchronous "store and forward" technologies (i.e., involving the secure sharing and reading of images) is currently permitted only in federal demonstration programs in Alaska or Hawaii. Improving access to these services offers both an opportunity to expand the geographic reach of providers in a growing number of specialties and a valuable resource for primary care provid- ers seeking those services for their patients. Expanded use of telemonitoring services, including home health monitoring, is another example that is proving successful in helping providers remain "connected" to their patients when they are at home or at a distance (Duckett, 2011). As described earlier in this section, although initial evidence of improved outcomes and patient satisfaction is positive, Medicare does not currently provide reimbursement for remote monitor- ing (also referred to as telemonitoring), nor does it include home health settings as approved "originating sites" for care--only as receiving sites (CMS, 2012a).

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EVIDENCE OF GEOGRAPHIC VARIATION 81 Finally, although Medicare does provide reimbursement for a limited number of telehealth services, this reimbursement is provided for services only when they are presented from an originating site located in a rural HPSA or in a county outside of an MSA. No reimbursement for services is provided for beneficiaries living in urban health professions shortage areas or for those who face other barriers to access, yet who may not live in a formally designated HPSA. Expanding the current list of authorized locations (e.g., to include urban health profession short- age areas) and sites of care (e.g., to include home health settings) offers further opportunities to improve access and to help ensure that the right care is provided, at the right time, and in the right place. While there are significant concerns about the costs of the initial investments in the tech- nology, technical challenges in using it, the security of personal health information transmitted over the Internet, the qualifications of the remote providers billing Medicare, the potential for legal liability issues, and potential competition with providers located at a geographic distance from beneficiaries, the benefits to patients of remote monitoring seem increasingly clear and worth further exploration. The Center for IT Leadership reported that savings owing to reduced transportation costs and face-to-face visits could potentially cover the cost of implementing telehealth (Dixon et al., 2008), and the New England Healthcare Institute (2009) estimated an annual national cost savings of up to $6.43 billion in reduced hospital readmission. AHRQ and HRSA have been funding telehealth research projects for several years (Dixon et al., 2008), and additional opportunities for demonstrations could be developed through the CMS Center for Medicare and Medicaid Innovation. Scope of Practice As the number of Medicare recipients increases due to demographic changes in the popula- tion, beneficiaries will have increasing needs to access primary and specialty care from qualified providers. Previous sections of this chapter documented the geographic variation in practice locations for certain primary care practitioners, showing that advanced practice RNs and NPs are more likely than physicians to provide primary care services and to choose to practice in shortage areas (AHRQ, 2011a,c; IOM, 2011; Skillman et al., 2012). Traditionally, discussions of workforce supply in primary care have focused on how to recruit and retain physicians into primary care rather than specialty care and to provide incentives for physicians to practice in underserved areas (Salinsky, 2010). 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. A particular area of concern and disagreement is whether physicians must always provide direct, onsite supervision to advanced practice RNs or nurse practitioners, physician assistants, pharmacists, and other licensed health professionals (National Health Policy Forum, 2011). The scope of practice of various health professions is often seen solely as a disagreement over professional autonomy between physicians and other health professionals, but it is also a regulatory and payment policy issue (Safriet, 2011). The current scope-of-practice laws, cre- dentialing requirements, and payment policies may be considered overly restrictive by health professionals who have been trained to provide certain services but who are prohibited from doing so by state laws or by payment policies. For example, states vary extensively on the independent authority of nurse practitioners to diagnose, order tests, and make referrals (UCSF Center for the Health Professions, 2007). Sixteen states and the District of Columbia have passed

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82 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT laws granting full plenary authority for nurse practitioners to practice under their own license without requiring physician supervision or collaboration. The IOM (2010) report The Future of Nursing recommended a joint federal and state effort to establish standard practice acts, and a Josiah Macy Foundation report on primary care recommended removal of regulatory barriers inhibiting NP options (Cronenwett and Dzau, 2010). Because the focus of this report is on geographic adjustment factors and how they affect both metropolitan and nonmetropolitan providers and access to care, it is important to note that issues related to scope of practice present some unique challenges for physicians, nurses, and other practitioners. Physicians in nonmetropolitan primary care practices, for example, may actually need to practice at a broader level than their metropolitan counterparts. NPs practicing in rural areas may find themselves the sole provider in a community, needing to practice to the fullest extent of their educational preparation, yet limited by a particular state's requirement of physician supervision that may be very difficult to achieve (Baker Institute, 2012; Safriet, 2011) (see Box 3-2). Scope-of-practice issues and payment policies are also related. For some years now, Medi- care Part B services provided by NPs are paid 85 percent of the amount physicians receive under the Medicare Fee Schedule for the same visit code. NPs may bill "incident to" a physician and receive 100 percent of the physician rate, but this assumes physician supervision and requires that the patient must have been seen first by a physician. There are exceptions to these payment rules under federal programs. Rural Health Centers funded by CMS actually require an NP or PA to be part of the rural practice, and reimbursement is not differentiated or based on provider type. Federally Qualified Health Centers, under HRSA's Bureau of Primary Care, also have unique policies for practice and billing for primary care services which are not provider specific, but based on the service. Some of the new performance-based payment initiatives and care delivery models designed to improve the efficiency of health care delivery and care management also may also affect the mix of health care practitioners. For example, the primary care bonus payment to NPs and PAs only occurs when they are super- vised by a physician. These new initiatives should be evaluated to determine their impact on interprofessional collaboration and health outcomes for beneficiaries (Baker Institute, 2012). SUMMARY Most Medicare beneficiaries have reasonably good access to care and most have a usual source of care. However, those who need to find a new primary care practitioner or specialist have some challenges. Minority beneficiaries in the most recent MedPAC beneficiary survey reported more problems finding specialists than in previous years, and that is a source for con- cern and additional monitoring in future surveys. Quality of care for Medicare beneficiaries has been improving slowly over the past several years, but as is true with the rest of health care, it is still notable for wide geographic variation as well as racial and ethnic disparities in outcomes. Previous studies have identified strong regional patterns of performance, but the committee's recommendations are focused at the profession and practitioner levels. Analysis of CAHPS data conducted for this report found that metropolitan areas tended to do better on measures of timeliness of access to care, while nonmetropolitan areas scored higher on communication with physicians and overall satisfaction with physicians. There was little evidence in the analysis to suggest that the committee's Phase I recommenda- tions, if implemented, would have a systematic impact that would either favor or disadvantage

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EVIDENCE OF GEOGRAPHIC VARIATION 83 BOX 3-2 State Variations in Nurse Practitioners' Scope of Practice The issue of restrictive state practice influencing where NPs practice is unique to NPs in that there is such wide variation by state as to regulation. Currently 16 states and the District of Columbia (see below) allow full plenary authority to NPs, meaning that they have independent authority to practice and to write prescriptions in clinical practice. These states tend to be inclusive of large rural areas (e.g., Alaska, Hawaii, Iowa, North Dakota, Oregon, and Washington). However, there are states with significant rural areas and provider shortages that have very restrictive regulations for NPs (e.g., Georgia and Alabama) where such regulations may be impacting the workforce and numbers of potential providers. Additionally, findings indicate that states with more progressive regulations actually have higher enrollments in NP programs compared to those with more restrictive laws (Kalist and Spurr, 2004). The more restrictive states also lose potential NPs to states that have more progressive practice acts and regulations that govern NP practice (Wing et al., 2005). The jurisdictions granting full plenary authority to NPs are Alaska New Hampshire Arizona New Mexico Colorado North Dakota District of Columbia Oregon Hawaii Rhode Island Idaho Vermont Iowa Washington Maine Wyoming Montana SOURCE: AANP, 2011. geographic areas based on their current levels of performance related to access and timeliness of care or quality. However, quality measurement is not a definitive science, and much more needs to be learned about the relationships between payment and quality. It seems apparent that there are geographic pockets with persistent access and quality prob- lems for Medicare beneficiaries, and that many of these pockets are in medically underserved rural and inner metropolitan 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 need to be addressed through other means. FINDINGS 1.Racial and ethnic minorities and low-income individuals face more barriers when trying to access care and receive a lower quality of care. 2. Health Professional Service Areas are the prevailing standard for representing underserved areas and thus are useful for comparing access, quality, and workforce supply across

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84 GEOGRAPHIC ADJUSTMENT IN MEDICARE PAYMENT geographic areas. Racial and ethnic minorities tend to be overrepresented in Health Professional Service Areas. 3.The available evidence does not show a strong positive relationship between changes in the level of payment and quality of care at the geographic level. 4.The geographic areas used for payment adjustment are large relative to the locations of specific underserved populations. Thus, geographic payment adjustment is a blunt instrument for resolving these more localized disparities and is not sufficiently targeted to be an appropriate use of resources. 5.General surgeons tend to have different patterns of practice in metropolitan and nonmetropolitan areas. Those in nonmetropolitan areas tend to provide more trauma and critical care for small hospitals. 6.Adequate access to primary care services is essential to a well-functioning health care system. 7.Nurse practitioners and physician assistants comprise major portions of the primary care workforce. They also provide a great deal of subspecialty and procedural care that also benefits beneficiaries. 8. Access to high-quality primary and specialty care for beneficiaries in medically underserved metropolitan and nonmetropolitan areas would be improved by increasing the availability and use of telehealth technologies. 9. The supply of and access to primary care services in underserved areas could be improved if state licensing and credentialing laws were consistent and allowed the full primary care workforce to practice to their full scope of educational preparation. REFERENCES AANP (American Academy of Nurse Practitioners). 2011. Collaboration/supervisory language in state practice acts and regulations for nurse practitioners. http://www.aanp.org/images/documents/state-leg-reg/ StateRegulatoryMap.pdf (accessed August 8, 2012). AANP. 2012. FAQs about nurse practitioners. http://www.aanp.org/NR/rdonlyres/A1D9B4BD-AC5E-45BF- 9EB0-DEFCA1123204/4710/2011FAQswhatisanNPupdated.pdf (accessed January 12, 2012). ACNP (American College of Nurse Practitioners). 2012. What is a nurse practitioner? http://www.acnpweb. org/i4a/pages/index.cfm?pageid=3479 (accessed March 14, 2012). AHRQ (Agency for Healthcare Research and Quality). 2010a. National healthcare quality report. http:// www.ahrq.gov/qual/qrdr10.htm (accessed October 12, 2011). AHRQ. 2010b. National healthcare disparities report. Rockville, MD: AHRQ. AHRQ. 2011a. Primary care workforce facts and stats: Overview. Rockville, MD: AHRQ. AHRQ. 2011b. Primary care workforce facts and stats: No. 1. The number of practicing primary care physi- cians in the United States. AHRQ Publication No. 12-P001-2-EF, October 2011. http://www.ahrq. gov/research/pcwork1.htm (accessed August 8, 2012). AHRQ. 2011c. Primary care workforce facts and stats: No. 2. The number of nurse practitioners and physician assistants practicing primary care in the United States. AHRQ Publication No. 12-P001-3-EF, http:// www.ahrq.gov/research/pcwork2.htm (accessed November 18, 2011). AHRQ. 2011d. Geographic distribution of health care professionals, 2010. Table 2. http://www.ahrq.gov/ research/pcwork3.htm (accessed August 8, 2012). AHRQ. 2012a. National quality measures clearinghouse. http://www.qualitymeasures.ahrq.gov/ (accessed December 12, 2011). AHRQ. 2012b. Primary care workforce facts and stats. Distribution of the U.S. primary care workforce. AHRQ Publication No. 12-P001-4-EF. http://www.ahrq.gov/research/pcworkforce.htm (accessed on Janu- ary 14, 2012).

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