workforce, including recruitment and retention, mobility between urban and rural areas, and the ability of hospitals and other facilities to maintain an adequate and skilled workforce in order to maintain access for beneficiaries. The committee was also asked to consider the effect of the adjustment factors on population health, quality of care, and the ability of providers to furnish efficient, high-value care.

Historically, policies and programs supported by the Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA) have sought to improve access to care in many different ways. In general, however, the policies have influenced the workforce directly, through training programs and payment policies to increase supply, or they have been targeted to maintain access through influencing the geographic distribution of facilities and health professionals. Medicare payment policies have also been tied to quality improvement for several years, originally for hospitals and increasingly also for ambulatory care and primary care providers, primarily physicians. The committee did not find sufficient evidence about the effect of payment policies on population health and high-value care to be able to include in its review, but it did discuss value-based purchasing and the workforce implications of new models of care that focus on care coordination.

Given the breadth of the committee’s charge, the committee chose to do a targeted review that focused on Medicare payment policies to address access, quality of care, and workforce supply and distribution and that also have a geographic component, such as a comparison of metropolitan and nonmetropolitan areas. This chapter begins with a review of Medicare policies and programs intended to promote beneficiaries’ access to hospital and primary care services provided by a variety of health professionals, and then it reviews policies intended to promote quality of care. The chapter then reviews workforce programs intended to improve the geographic distribution of practitioners through recruitment and retention efforts, focusing on program evaluations and other evidence that the programs are successful in improving access, especially in Health Professional Shortage Areas (HPSAs). The chapter then discusses the many gaps in the evidence it reviewed and the need for a coordinated approach to collecting workforce data, designing programs, and setting national workforce targets and goals. The chapter closes with the committee’s findings related to access, quality of care, and workforce programs and policies.


Given the committee’s focus on the impact of geographically based payment adjustments on access in medically underserved areas, hospitals that are important or sole sources of hospital care for Medicare beneficiaries were of particular concern. Medicare’s payment policies that are intended to preserve access to hospital care in geographically isolated areas focus on five types of hospitals: critical access hospitals, sole community hospitals, Medicare-dependent hospitals, low-volume hospitals, and rural referral centers (see Table 4-1). However, the policies that apply to these hospitals tend to be inconsistent, and there is no mechanism for ensuring that the policies serve their stated purpose.

Nearly 1,300 hospitals have been designated as critical access hospitals, based on their size and the lack of another hospital within a specified distance.1 The critical access program is


1 Medicare Payment Advisory Commission. Payment Basics: Critical Access Hospitals Payment System, revised October 2011. Available at Critical access hospitals are limited to 25 acute care beds and must be at least 35 miles by primary road or 15 miles by secondary road from the nearest hospital; until 2006, hospitals also could qualify as critical access hospitals if they were designed a “necessary provider” by their state.

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