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Committee on Geographic Adjustment Factors in Medicare Payment Board on Health Care Services Margaret Edmunds, Frank A. Sloan, and A. Bruce Steinwald, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee respon- sible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHS P23320042509XI, Task Order No. HHS P23337012T between the National Academy of Sciences and the Centers for Medicare & Medicaid Services. Any opin- ions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Geographic Adjustment Factors in Medicare Payment. Geographic adjustment in Medicare payment. Phase II, Implications for access, quality, and efficiency / Committee on Geographic Adjustment Factors in Medicare Payment, Board on Health Care Services ; Margaret Edmunds and Frank A. Sloan, and A. Bruce Steinwald, editors. p. ; cm. Implications for access, quality, and efficiency Includes bibliographical references and index. ISBN 978-0-309-25798-5 (pbk.) -- ISBN 978-0-309-25799-2 (pdf) I. Edmunds, Margaret. II. Sloan, Frank A. III. Steinwald, Bruce. IV. Title. V. Title: Implications for access, quality, and efficiency. [DNLM: 1. Medicare Part A--economics. 2. Medicare Part B--economics. 3. Fee-for-Service Plans--organization & administration--United States. 4. Professional Practice Location--economics--United States. WT 31] 368.4'20140973--dc23 2012040470 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Geographic adjustment in Medicare payment: Phase II: Implications for access, quality, and efficiency. Washington, DC: The National Academies Press.

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"Knowing is not enough; we must apply. Willing is not enough; we must do." --Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administra- tion and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the supe- rior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initia- tive, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sci- ences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON GEOGRAPHIC ADJUSTMENT FACTORS IN MEDICARE PAYMENT FRANK A. SLOAN (Chair), J. Alexander McMahon Professor of Health Policy and Management, Professor of Economics, Center for Health Policy, Duke University, Durham, NC M. ROY WILSON (Vice-Chair), Chancellor Emeritus, University of Colorado Denver JON B. CHRISTIANSON, Professor and James A. Hamilton Chair in Health Policy and Management, University of Minnesota School of Public Health, Minneapolis STUART GUTERMAN, Vice President, Payment and System Reform, The Commonwealth Fund, Washington, DC CARLOS R. JAÉN, Chair of Family and Community Medicine and Dr. John M. Smith, Jr. Endowed Professor, University of Texas Health Science Center at San Antonio JACK KALBFLEISCH, Professor of Biostatistics and Statistics and Director, Kidney Epidemiology and Cost Center, University of Michigan School of Public Health, Ann Arbor MARILYN MOON, Senior Vice President and Director, Health, American Institutes of Research, Washington, DC CATHRYN NATION, Associate Vice President, Division of Health Sciences and Services, University of California Office of the President, Oakland JOANNE M. POHL, Professor Emerita, Division of Health Promotion and Risk Reduction, University of Michigan School of Nursing, Ann Arbor THOMAS C. RICKETTS III, Managing Director, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill JANE E. SISK, Institute of Medicine Scholar-in-Residence, and Former Director, Division of Health Care Statistics, Centers for Disease Control and Prevention, National Center for Health Statistics, Washington, DC A. BRUCE STEINWALD, Independent Consultant, Washington, DC DAVID VLAHOV, Dean and Professor, School of Nursing, University of California, San Francisco BARBARA O. WYNN, Senior Policy Analyst, RAND Corporation, Arlington, VA ALAN M. ZASLAVSKY, Professor, Health Care Policy (Statistics), Harvard Medical School, Boston, MA STEPHEN ZUCKERMAN, Senior Fellow, Health Policy Center, The Urban Institute, Washington, DC RTI International Consultants WALTER ADAMACHE, Research Economist JUSTINE L.E. ALLPRESS, Research Geospatial Programmer/Analyst KATHLEEN DALTON, RTI Project Director, Senior Health Policy Analyst GREGORY C. POPE, Program Director, Health Care Financing and Payment Program ELIZABETH SEELEY, Health Economist NATHAN WEST, Health Services Analyst ALTON WRIGHT, Public Health Analyst v

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IHS Global Insight Consultants TIM DALL, IHS Project Director, Managing Director PAUL GALLO, Project Staff MIKE STORM, Project Staff Study Staff MARGARET EDMUNDS, Study Director KATHLEEN HADDAD, Senior Program Officer (August 2010 to November 2011) JENSEN JOSE, Research Associate (December 2011 to March 2012) SERINA S. RECKLING, Research Associate (September 2010 to November 2011) SARA SPIZZIRRI, Research Assistant (August 2010 to March 2012) JOI D. WASHINGTON, Research Assistant (August 2011 to January 2012) ASHLEY McWILLIAMS, Senior Program Assistant (August 2010 to August 2011) ROGER C. HERDMAN, Director, Board on Health Care Services vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspec- tives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Robert Berenson, The Urban Institute Karen Heller, Greater New York Hospital Association Keith J. Mueller, University of Iowa Joseph Newhouse, Harvard University Robert Phillips, Robert Graham Center for Policy Studies in Family Medicine and Primary Care Douglas Reding, Marshfield Clinic William Scanlon, Independent Consultant Susan M. Skillman, University of Washington George Stamas, Bureau of Labor Statistics David Torchiana, Massachusetts General Physicians Organization Lance A. Waller, Emory University, Rollins School of Public Health Although the reviewers listed above have provided many constructive comments and sug- gestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by vii

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viiiREVIEWERS Harold Sox, American College of Physicians, and Charles E. Phelps, Rochester University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accor- dance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Acknowledgments T he Committee on Geographic Adjustment Factors in Medicare Payment and the Institute of Medicine (IOM) study staff would like to thank the many individuals and organizations who generously contributed their time, knowledge, and expertise to this Phase II report. The following individuals shared their expertise through invited presentations at the public session in September 2011: Cindy Bagwell, Vice President for Talent Acquisition, Geisinger Health System, Danville, PA; Blair Childs, Senior Vice President, Premier, Inc.; James Dickson, CEO, Copper Queen Community Hospital, Bisbee, Arizona; Kathy Duckett, Director of Clinical Programs, Partners Home Care, Boston, MA; Jennifer Grebenschikoff, President, The Physician Executive Leadership Center, Tampa, FL; Mark Miller, Executive Director, MedPAC, Washington, DC; Rachel Morgan, National Conference of State Legislatures, Washington, DC; and Anne Rosewarne, President, Michigan Health Council, Okemos, MI. Several others provided valuable information and technical assistance. Phil Doyle, Laurie Salmon, and George Stamas of the Bureau of Labor Statistics met with committee members and staff and provided statistical consultations and data for the committee's consideration. Others were instrumental in identifying speakers for the public session and in providing materials and information for the committee's consideration: Alex Calgano of the Massachusetts Medical Society; Linda Fishman, Don May, and Joanna Kim of the American Hospital Association; Atul Grover of the American Association of Medical Colleges; Elizabeth McNeil of the California Medi- cal Association; Brent Miller of Marshfield Clinic; Mark Miller, Jeffrey Stensland, Kevin Hayes, Cristina Boccutti, and Arielle Mir of MedPAC; Robert Phillips, Director of the Robert Graham Center: Policy Studies in Family Medicine and Primary Care; Edward Salsberg of the Health Resources and Services Administration; and Jan Towers, Health Policy Director of the American Academy of Nurse Practitioners. Several congressional staff members also provided valuable background information for the study. They include professional staff members Nick Bath of the Senate Health, Energy, Labor and Pensions Committee; Celina Cunningham, Office of Congressman Jay Inslee; Jennifer Friedman and Geoff Gerhardt of the House Committee on Ways and Means, Subcommittee on ix

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xACKNOWLEDGMENTS Health; Heather Gasper, Office of Congressman Michael E. Capuano; Mike Goodman, Office of Congressman Bruce Braley; Tim Gronniger, House Committee on Energy and Commerce; Jenn Holcomb, Office of Congresswoman Betty McCollum; John Laufer, Office of Congressman Pierluisi; and Travis Robey, Office of Congressman Ron Kind. The expertise of Jim Jensen, Executive Director of the Office of Congressional and Govern- ment Affairs, in facilitating communications with congressional staff and members is gratefully acknowledged. Special thanks go to the staff at RTI International, whose statistical analyses and techni- cal consultations were both integral and invaluable to the study: Kathleen Dalton, RTI Project Director; Greg Pope, Program Director; and team members Walter Adamache, Justine Allpress, Elizabeth Seeley, Nathan West, and Alton Wright. Several members of the IOM staff offered their guidance and support to the study staff and committee, including Roger Herdman, Director of the Board on Health Care Services; Senior Program Officers Jill Eden, Robin Grant, and Cheryl Ulmer and Program Officers Meg McCoy and Rob Saunders. Assistance and project support from Chelsea Frakes, Jillian Laffrey, and Michael Park is also gratefully acknowledged. Harvey Fineberg, President, and Judith Salerno, the Leonard D. Schaeffer Executive Officer, also provided valuable advice at key stages of the study. The guid- ance of Porter Coggeshall, Executive Director of the Report Review Committee, was especially valuable throughout the report review process. The Study Director would like to thank Marton Cavani, Web Communications Manager; Laura Harbold DeStefano, Editorial Projects Manager; Diedtra Henderson, Office of Reports and Communications; Stephen Mautner, Executive Editor, The National Academies Press; Abbey Meltzer, Deputy Communications Director; Christine Stencel, Senior Media Relations Officer; and Lauren Tobias, Director of Communications, for their creative approaches to helping the staff plan for report dissemination. The committee could not have accomplished its tasks without the leadership of the Study Director, Margo Edmunds, whose management skills and foresight were exemplary. Finally, the committee and staff would like to thank the Centers for Medicare & Medicaid Services (CMS), whose funding made this study possible. We especially thank Jonathan Blum, Deputy CMS Administrator; Marc Hartstein, Acting Director, Hospital and Ambulatory Policy Group; and Judith Richter, Division of Acute Care.

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Contents BOXES, EXHIBITS, FIGURES, AND TABLES xiii ACRONYMS xix SUMMARY: IMPLICATIONS OF GEOGRAPHIC ADJUSTMENT FOR ACCESS, QUALITY, AND EFFICIENCY OF CARE 1 1 INTRODUCTION AND OVERVIEW 13 Background, 13 Conceptual Approach to Geographic Adjustment, 14 Results of Impact Analyses from Phase I Recommendations, 19 References, 20 2 PAYMENT SIMULATIONS 23 Introduction, 23 Overview of Findings, 25 Effects on Hospital Payments, 27 Effects on Physician Payments, 31 Examples of Provider Impact, 44 Key Findings and Conclusions, 47 References, 50 3EVIDENCE OF GEOGRAPHIC VARIATION IN ACCESS, QUALITY, AND WORKFORCE DISTRIBUTION 51 Geographic Variation in Access to Health Care, 52 Geographic Variation in Quality of Care, 58 Workforce Distribution and Supply, 64 xi

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xiiCONTENTS Expanding Opportunities to Improve Access, 74 Summary, 82 Findings, 83 References, 84 4PROGRAMS AND POLICIES TO IMPROVE ACCESS AND QUALITY OF CARE FOR BENEFICIARIES 91 Introduction, 91 Medicare Payment Policies Intended to Maintain Access to Hospital Care, 92 Programs That Encourage Clinical Practice in Underserved Areas, 96 Current Programs to Improve Quality, 100 Current Programs to Improve Workforce Supply and Access, 104 Empirical Evidence on Effects of Public Policies to Improve Geographic Distribution of Health Care Practitioners, 107 Delivery System Reform Initiatives to Promote Access and Quality of Care, 114 Policy Considerations Affecting Workforce Distribution, 117 Findings, 119 References, 119 5 OBSERVATIONS ON THE LARGER POLICY CONTEXT 125 Unintended Effects of Medicare Payment Policies, 126 Disparities in Access to Care, 129 Geographic Adjustment and Payment Reform, 130 Conclusion, 132 References, 132 6 RECOMMENDATIONS 135 Conclusion, 141 APPENDIXES A-1 Technical Approach to Payment Simulations: IOM Committee Recommendations for Hospital Wage Index and Physician Geographic Adjustment Factors 143 A-2 Payment Simulations: Data Tables 173 B Methods for the Analysis of Associations of Quality Measures with Payments in Chapter 3 175 C Quality Assurance for RTI Payment Simulations 183 D Public Session: Workforce, Access, and Innovation: Policy Levers for Geographic Adjustment in Medicare Payment 187 E Exchange of Letters Between House of Representatives Quality Coalition and Committee Chair Frank Sloan 189 F Committee and Staff Biographies 195 INDEX209

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Boxes, Exhibits, Figures, and Tables Summary Box S-1 Statement of Task, 2 Chapter 1 Boxes 1-1 Statement of Task, 15 1-2 Principles from the Phase I Report, 16 1-3 Definitions Used in This Report, 17 Table 1-1 Policy Context for Evidence Review, 20 Chapter 2 Boxes 2-1 Phase I Recommendations Pertaining to Payment Simulations, 25 2-2 Summary of the Committee's Commuter Smoothing Recommendation, 29 2-3 Summary of the Hospital Wage Index (HWI), 32 2-4 Summary of the Physician Geographic Practice Cost Indexes (GPCIs) and Aggregate Geographic Adjustment Factor (GAF), 35 2-5 Further Narrative on Alaska and Puerto Rico, 48 xiii

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xiv BOXES, EXHIBITS, FIGURES, AND TABLES Figures 2-1 Payment differences between IOM committee recommended adjusters and current CMS policy: Distribution across measures of service delivery, 26 2-2 Distribution of payment effects of IOM committee recommendations on the hospital index, 28 2-3 Distribution of payment effects of IOM committee recommendations on the GPCIs, 36 2-4 Payment effects attributed to market redefinition, by county status and type of payment locality, 38 2-5 Combined physician payment effects by Rural­Urban Continuum Code, 40 2-6 Sample state map identifying payment impact and HPSA status by county, 43 Tables 2-1 Summary of Institute of Medicine Committee Phase I Recommendations Included in the Payment Simulations, 26 2-2 Differences in Payments by IPPS Hospital Reclassification, 32 2-3 Differences in IPPS Payments by Special Rural Status, 33 2-4 Percent Changes in the Medicare Hospital Wage Indexes: Year-to-Year Actual Changes Compared to Simulated Changes from IOM Committee Recommendations, 34 2-5 Distribution of Counties and Beneficiaries Across Newly Constructed HPSA Categories, 41 2-6 Combined Physician Payment Effects by Health Professional Shortage Area Status and Metropolitan Location, 41 Chapter 3 Boxes 3-1 Health Professional Shortage Areas (HPSAs): History and Methodology, 56 3-2 State Variations in Nurse Practitioners' Scope of Practice, 83 Figures 3-1 County designations for nonmetropolitan primary care service shortage areas, 57 3-2 HPSA county designations for metropolitan primary care service shortage areas, 58 3-3 National occupational employment estimates, 2000­2010, for selected populations, 65 3-4 Number of primary care professionals, 67 3-5 Change in physicians per 100,000 population, 2004­2009, 68 3-6 Distribution of primary care physicians among urban and nonurban areas, 69 3-7 Change in primary care physicians per 100,000 population, 2004­2009, 70 3-8 Change in general surgeons­to-population ratios, 71 3-9 Registered nurses per 100,000 population, 2011, 72 3-10 Rural per capita supply of nurse practitioners by state, 2010, 74

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BOXES, EXHIBITS, FIGURES, AND TABLES xv 3-11 Urban per capita supply of nurse practitioners by state, 2010, 75 3-12 Growth of PAs per 100,000 population, 76 3-13 Counties with no PAs, 77 Tables 3-1 Sample Measures Included in the Evidence Review, 52 3-2 Description of CAHPS Items, Number of Responses, and Rate of "Top Box" (Most Favorable) Responses, 60 3-3 Geographic Distribution of Primary Care Health Care Professionals, 2010, 73 3-4 Medicare Payments for Telehealth Services, 78 Chapter 4 Boxes 4-1 Do Quality Incentive Payments Work?: Results from the Premier Hospital Quality Incentive Program, 103 4-2 Expected Earnings and Physician Specialty Choices, 106 Table 4-1 Access to Hospital Care in Geographically Isolated Areas, 93 Chapter 5 Box 5-1Key Disparity Measures from Department of Health and Human Services Action Plan to Reduce Racial and Ethnic Health Disparities, 130 Figure 5-1Primary care billings reflect a higher proportion of total RVUs in nonmetropolitan areas, 128 Appendix A-1 Exhibits A-1 Recommended Changes in Index Construction Incorporated into Payment Simulations, 145 A-2 Labor Markets in Source Data and Final Index Construction, 147 A-3 Percent difference in HWI values due to data change alone, plotted against number of hospitals in labor market, 148 A-4 Effects of Adjusting for Independent Area Variation in Benefits, 149

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xvi BOXES, EXHIBITS, FIGURES, AND TABLES A-5 County Assignments by Region, Type of Payment Locality, and CBSA Market, 151 A-6 County Smoothing Adjustments, by Type of Index, 152 A-7 Commuter-based smoothing adjustments by Rural­Urban Continuum Code, 153 A-8 IOM Committee's Recommended Smoothing Adjustments Compared to Current Outmigration Adjustments Under "Section 505" and Related Reclassifications, 154 A-9 Correlation of Adjusted ZIP Code­to-County Address Counts to Population and Beneficiary Statistics, 156 A-10 Distribution of estimated proportion of county population in primary care shortage areas, 156 A-11 Distribution of Counties, Part B Enrollees, and RVUs Billed by Primary Care Practitioners, by Revised HPSA County Status, 157 A-12 Budget Neutrality Factors Imposed on IOM Committee Indexes, 162 A-13 Distribution of payment impact across all IPPS hospitals, 163 A-14 Estimated Change in IPPS Payments, Isolated by Type of IOM Committee Recommendation, 164 A-15 Impact of IOM Committee Recommendations on IPPS Payment, by USDA Rural­ Urban Continuum Code, 165 A-16 Impact of IOM Committee Recommendations on IPPS Payment, by Census Division and Metropolitan Status, 165 A-17 Impact of IOM Committee Recommendations on IPPS Payment, by Hospital Reclassification Status, 166 A-18 Impact of IOM Committee Recommendations on IPPS Payment, by Special Rural Status, 166 A-19 Impact of IOM Committee Recommendations on IPPS Payment, by Teaching and DSH Status, 166 A-20 Impact of IOM Committee Recommendations on IPPS Payment, by Bed Size, 167 A-21 Distribution of physician payment impact across all counties, 167 A-22 Change in Aggregate Geographic Adjustment Factor, by Type of IOM Committee Recommendation, 168 A-23 County Analysis of the Isolated Payment Effects from Redefining the GPCI Payment Areas, 169 A-24 Physician Payment Impact of IOM Committee Recommendations, by USDA Rural­ Urban Continuum Code, 170 A-25 Physician Payment Impact of IOM Committee Recommendations, by Revised Health Professional Shortage Area Indicator, 170 A-26 Physician Payment Impact of IOM Committee Recommendations, by County Ranking in Median Family Income, 171 A-27 Physician Payment Impact of IOM Committee Recommendations, by County Ranking in Percent Non-White Population, 171 A-28 Physician Payment Impact of IOM Committee Recommendations, by Rural County Population Density, 171 A-29 Physician Payment Impact of IOM Committee Recommendations, by Percent of Total RVUs Accounted for by Primary Care Practitioners, 172 A-30 Effect of Level of Physician Work GPCI on Estimated IOM Committee Payment Differences, for Counties Grouped by Revised Health Professional Shortage Area Indicators, 172

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BOXES, EXHIBITS, FIGURES, AND TABLES xvii Appendix B Tables B-1 Coefficients of HPSA Category Dummies, 179 B-2 Coefficients of RUCC Category Dummies, 180 B-3 Comparison of Variation Among HPSA Category Coefficients Without and With Control for GAF or GPCI, 181 B-4 Comparison of Variation Among RUCC Category Coefficients Without and With Control for GAF or GPCI, 181 B-5 Coefficients of GAF and GPCI, Without Controls and With Controls for HPSA or RUCC, 182 B-6 Coefficients of Difference Between Current (CMS) and Proposed (IOM) Factors (as IOM­CMS), With and Without Control for RUCC, 182 Appendix C Exhibit C-1 Quality Assurance Protocols and Quality Control Activities, 186

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Acronyms ACA Patient Protection and Affordable Care Act ACS American Community Survey AHEC Area Health Education Center AHRQ Agency for Healthcare Research and Quality AMA American Medical Association ASC ambulatory surgical center BLS Bureau of Labor Statistics BPC Bipartisan Policy Center CAH critical access hospital CAHPS Consumer Assessments of Healthcare Providers and Systems CBSA core-based statistical area CHC community health center CMI case-mix index CMS Centers for Medicare & Medicaid Services COGME Council on Graduate Medical Education CPT Current Procedural Terminology CRS Congressional Research Service CSA combined statistical area CTS Community Tracking Survey CY calendar year DoD Department of Defense DRG diagnosis-related group DSH disproportionate share hospital xix

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xxACRONYMS EHR electronic health record FCC Federal Communications Commission FQHC Federally Qualified Health Center FY fiscal year GAF geographic adjustment factor GAO Government Accountability Office GIS geographic information system GME graduate medical education GPCI geographic practice cost index GSA General Services Administration HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems Survey HCFA Health Care Financing Administration HCPCS Healthcare Common Procedure Coding System HHA home health agency HHS Department of Health and Human Services HIT health information technology HITECH Health Information Technology for Economic and Clinical Health Act of 2009 HPSA Health Professional Shortage Area HRR hospital referral region HRSA Health Resources and Services Administration HSA hospital service area HSIP Healthcare Shortage Professional Area (HPSA) Surgical Incentive Payment HUD Department of Housing and Urban Development HWI hospital wage index IME indirect medical education IMG international medical graduate IOM Institute of Medicine IPPS Inpatient Prospective Payment System IRS Internal Revenue Service KFF Kaiser Family Foundation LPN licensed practical nurse MDH Medicare-dependent hospital MedPAC Medicare Payment Advisory Commission MEPS Medical Expenditure Panel Survey MGCRB Medicare Geographic Classification Review Board MGMA Medical Group Management Association microSA micropolitan statistical areas MIPPA Medicare Improvements for Patients and Providers Act MMA Medicare Modernization Act of 2003

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ACRONYMS xxi MPmalpractice MS-DRG Medicare severity diagnosis-related group MSA metropolitan statistical area NAICS North American Industry Classification Systems NCS National Compensation Survey NHDR National Healthcare Disparities Report NHQR National Healthcare Quality Report NHSC National Health Service Corps NP nurse practitioner NPI National Provider Identifier OBRA Omnibus Budget Reconciliation Act of 1989 OES Occupational Employment Statistics OIG Office of Inspector General OMA occupational mix adjustment PA physician assistant PCSA primary care service area PE practice expense PFS Physician Fee Schedule PHS Public Health Service PLI professional liability insurance PPIS Physician Practice Information Survey PPS prospective payment system PQRS Physician Quality Reporting System ProPAC Prospective Payment Advisory Commission RBRVS Resource-Based Relative Value Scale RN registered nurse RSE relative standard error RRC rural referral center RUCC Rural­Urban Continuum Code RVU relative value unit SCH sole community hospital SE standard error SNF skilled nursing facility UDS Uniform Data Systems

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