Geographic Adjustment in Medicare Payment Phase II: Implications for Access, Quality, and Efficiency (2012) / Chapter Skim
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4 Programs and Policies to Improve Access and Quality of Care for Beneficiaries
4 Programs and Policies to Improve Access and Quality of Care for Beneficiaries
Pages 91-124
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From page 91... ...
Among the newest Medicare payment policies are those that move practitioner compensation from traditional fee-for-service models to bundled payments and other incentives for care teams to coordinate care across organizations and settings. These policies are encouraging new delivery models that are intended to improve efficiency and provide a better quality of patient experience, but their likely influence on the workforce supply, distribution, and training programs is not yet clear.
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From page 92... ...
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)
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From page 93... ...
It furnishes 24-hour emergency care services 7 days per week. Sole A hospital must meet one of the following The SCH is paid whichever amount results community criteria: in the greatest aggregate payment in a cost hospital 1.
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From page 94... ...
Critical access hospitals are paid based on their current Medicare allowable costs; because the committee's recommendations apply only to those hospitals that are paid under Medicare's inpatient prospective payment system for hospital services, critical access hospitals are not affected by the committee's recommendations on the hospital wage index. The special protections afforded to about 400 sole community hospitals are intended to support their unique role in providing access to inpatient hospital care to the residents of a geographic area.
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From page 95... ...
Unlike critical access hospitals and sole community hospitals, Medicare-dependent hospitals are not designated based on the lack of alternative sources of care available to Medicare beneficiaries, but only on their small size and high proportion of Medicare patients. As a result, this program is not as well targeted to preserving access to care in geographically isolated areas.
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From page 96... ...
government has funded community health centers (CHCs) to provide primary care services to underserved populations in metropolitan and nonmetropolitan areas, including low-income and uninsured populations.
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From page 97... ...
recruit, train, and retain health professionals to work with underserved populations by developing partnerships among medical, nursing, and allied health schools to help meet local health care needs (HRSA, 2012c)
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From page 98... ...
Given its small size, important effects on HPSA practitioner workforce could not be expected, and the same may be true of the Affordable Care Act bonus program. Given that the more recent bonus payments have only been available for about a year, it is too early to evaluate their effects on the primary care workforce.
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From page 99... ...
were even further away. Primary care physicians locate their practices in communities of all sizes, so a close link would be expected between primary care availability, especially general and family practitioners, and access to primary care services.
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From page 100... ...
Hospital Inpatient Quality Reporting Program For the past 6 years, CMS has been administering the Hospital Inpatient Quality Reporting Program,3 which is designed to incentivize IPPS hospitals, through Medicare Part A payments, to report their quality of care measures to CMS (CMS, 2009)
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From page 101... ...
Readmission rates have been found to vary by hospital and by geographic area, even for the same level of severity for the same disease. This variation suggests that some readmissions could be prevented if there were better care management, particularly at discharge as beneficiaries transition to other care settings, such as their homes, skilled nursing facilities, or other postacute care (CRS, 2010)
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From page 102... ...
Payment Policies and Quality Measures for Physicians and Other Providers Since 2006, CMS has been collecting quality data measures from physicians and other eligible practitioners6 paid under the Physician Fee Schedule under the Physician Quality Reporting System (PQRS)
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From page 103... ...
Initiated in 2003, the Premier Hospital Quality Incentive Program is a CMS demonstration project that recognizes and provides financial incentives to participating Inpatient Prospec tive Payment System hospitals that demonstrate high-quality performance. Hospitals are ranked based on quality measures for the following medical conditions: heart attacks, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacements.
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From page 104... ...
Practitioners also show variation in the importance they place on both financial and nonfinancial characteristics of their practice locations. On the financial side, income per professional in areas that are generally attractive may be lower than in those areas that are relatively unattractive, because salaries and/or bonuses may be higher to attract health professionals.
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From page 105... ...
Using American Medical Association Masterfile data to study physician diffusion between 1981 and 2001, Ricketts and Randolph (2007) also found a small net flow from urban to rural areas, which they attributed to workforce programs that are intended to counter the normal market pressures for health professionals to locate in urban areas.
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From page 106... ...
Nicholson (2008) analyzed the relationship between earnings expectations by specialty and specialties that medical students preferred to enter.
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From page 107... ...
. Data sources included historical Title VII9 training files, cross-sectional data about current specialties and practice locations, and a 5-year cross-section of service in Rural Referral Centers and Federally Qualified Health Centers.
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From page 108... ...
The committee looked for literature on the impact of Medicare's payment policies on health professionals' location decisions. Although payment policies may affect location and policy makers should consider the possibility that their decisions could affect health professionals' location decisions, the committee found no conclusive empirical evidence specifically linking payment policies to such choices.
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From page 109... ...
(1994a) analyzed data on cohorts of NHSC and a comparison group of non-NHSC physicians over the period 19871990, finding that retention rates11 were about the same for NHSC as for the comparison group immediately after the NHSC obligation was satisfied, but beginning at 3 years postobligation, the NHSC physicians were less likely to remain at their practice sites.
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From page 110... ...
Resident support programs provide financial assistance to residents with 1- to 2-year service requirements at the end of the residency. The aggregate number of health professionals receiving subsidies was small; an estimated 1,215 practitioners signed initial contracts and 1,676 (of whom four-fifths were physicians)
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From page 111... ...
immigration policies as they apply in general and to health professionals in particular and expanded capacity in U.S. residency programs that exceeds the level that can be filled by U.S.
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From page 112... ...
(1994b) inquired whether retention in rural practice is of longer duration for public medical school than for private medical school graduates, for those who participated in community hospital-based residencies, and for physicians who had participated in rural rotations as medical students and residents.
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From page 113... ...
Respondents were asked about rural training experiences as well as more general questions about their medical education. They found that among non-NHSC physicians practicing in subsidized rural practices at follow-up, retention duration could not be predicted by ownership of medical school, training in community hospital-based residencies, or participation in rural training experiences as medical students or residents.
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From page 114... ...
In general, while a variety of programs attempt to enhance recruitment, retention, or both, we know very little about which types of policies are most successful in improving access in underserved areas. CMS and HRSA are both HHS agencies, but policies to enhance access to primary care services have not been jointly developed.13 Indeed, Medicare payment policies that promote specialization and a large income gap between primary care practitioners and specialists have likely worked at cross-purposes with the objectives of Public Health Service programs to improve access in underserved areas.
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From page 115... ...
. CMS has established two ACO payment programs to provide financial incentives for Medicare-enrolled providers who come together to form an ACO: the Medicare Shared Savings Program and the Advance Payment Model.
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From page 116... ...
. From a workforce perspective, one of the more controversial aspects of ACOs is that beneficiaries are attributed to ACOs on the basis of which primary care physician provided a plurality of their primary care services.
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From page 117... ...
. Incentive Payments for Coordination of Care New bonus payments for primary care practitioners are funded under the Affordable Care Act to improve coordination of care.
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From page 118... ...
In settings where these practitioners are salaried employees paid by the supervising physicians, the payment benefits accrue to the physicians as employers, and in settings where NPs are paid by hospitals, any payment benefits accrue to hospitals. To help expand access to primary care services, an incentive payment of 10 percent of the amount is paid quarterly under the Physician Fee Schedule for primary care services provided by primary care physicians (defined as those trained and practicing in family medicine, internal medicine, pediatrics, and geriatrics)
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From page 119... ...
has not been adequately evaluated, and it will take time before there is enough information and experience to evaluate other recently introduced bonus payments. 3.Medicare's payment policies related to quality of care are important, but there is no evidence that geographic adjustment is related to quality of care.
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From page 120... ...
2011d. Hospital quality initiatives: Hospital inpatient quality reporting program.
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From page 121... ...
2012h. Fact sheets: First accountable care organizations under the Medicare shared savings program.
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From page 122... ...
community health centers. Health Affairs 25(6)
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From page 123... ...
1995. Area health education centers: A role in enhancing the rural practice environment.
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From page 124... ...
2012. The Obama administration and community health centers.
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