Geographic Adjustment in Medicare Payment Phase II: Implications for Access, Quality, and Efficiency (2012) / Chapter Skim
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3 Evidence of Geographic Variation in Access, Quality, and Workforce Distribution
3 Evidence of Geographic Variation in Access, Quality, and Workforce Distribution
Pages 51-90
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From page 51... ...
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.
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From page 52... ...
Those studies are summarized 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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From page 53... ...
. 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)
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From page 54... ...
As the next sections show, where access problems exist, they are generally 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.
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From page 55... ...
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.
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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)
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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)
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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 conditions in hospital and outpatient settings (AHRQ, 2010a; Jencks et al., 2003)
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From page 59... ...
. 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)
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From page 60... ...
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)
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From page 61... ...
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 relationship between levels of payment and geographic variation in quality, the findings should be viewed only as suggestive, for several reasons.
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It is also important to note that HPSAs are by definition areas in which nonmarket interventions (such as bonus payments) are implemented to correct perceived failures of the health professional market.
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The committee's analysis of CAHPS data yielded little evidence that Medicare payment policy drives differences in quality of care received by beneficiaries; however, the analysis did suggest that metropolitan areas tended to do better on 8 The NHQR and NHDR both use four classifications of metropolitan (large central, large fringe, medium, and small) and two categories of nonmetropolitan (micropolitan and noncore)
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According to MedPAC (2011) , half of the health professionals in Medicare's clinical registry are physicians, and the other half include nurse practitioners (NPs)
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From page 65... ...
Most studies determining the number and geographic distribution of the health care workforce focus on a few key professions -- physicians, nurses, dentists, mental health professionals, and a few other health professionals -- but not the entire health care workforce (Baker Institute, 2012; Bipartisan Policy Center, 2011)
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A recent microsimulation study projected the need for an additional 8,000 nurse practitioners and 2,400 physician assistants in primary care, particularly in areas with low physician supply (Baker Institute, 2012; Dall, 2010)
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. Geographic Distribution of Physicians Primary Care Physicians The distribution of primary care physicians has been identified as a policy problem for many years, and a previous IOM report specifically identified primary care shortages in rural areas and inner cities (IOM, 1996a)
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. As of 2010, about 13 percent of primary care physicians practiced in rural areas (see Figure 3-6)
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86% 8% 4% General Pediatrics 91% 6% General Internal Medicine 90% 7% Family Physicians/GPs 78% 11% 7% 4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Urban Large rural Small rural Remote rural/frontier FIGURE 3-6 Distribution of primary care physicians among urban and nonurban areas. NOTE: GP = general practitioner.
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From page 70... ...
Geographic Distribution of Registered Nurses and Nurse Practitioners Registered Nurses Registered nurses (RNs) are the largest occupational group in health care, and 2.7 million RNs were employed in the United States in 2010 (BLS, 2012a)
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From page 71... ...
SOURCE: Christian Lynge et al., 2008. Figure 3-8.eps Nurse Practitioners NPs are registered nurses who have completed graduate-level education and clinical training12 to provide a wide range of preventive and acute health care services, including primary, specialty, and subspecialty care (AANP, 2012; ACNP, 2012)
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pdf. Definitions: registered nurses include advance practice nurses such as nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists; employment refers to the number of workers who can be classified as full- or part-time employees, including workers on paid vacations or other types of paid leave.
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From page 73... ...
SOURCE: AHRQ, 2011d. HRSA's 2008 National Sample Survey of RNs reported a total of 158,348 NPs, and the American Academy of Nurse Practitioners reported 140,000 practicing NPs in 2011 (AANP, 2012)
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. EXPANDING OPPORTUNITIES TO IMPROVE ACCESS Recent Developments in the Use of Telehealth Services One very promising and rapidly developing strategy to improve access to care for beneficiaries is to provide practicing clinicians with new resources and technology tools that enable them to reach more patients.
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Table 3-4 summarizes the current Medicare payments for telehealth. Increasingly, the term telehealth is replacing telemedicine terminology with expanded definitions that refer to the use of technology-enabled delivery of services to facilitate the monitoring, diagnosis, treatment, management, care, and education of patients who are at a distance from the providers.
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The most recent measure, approved in California in 2011, expands opportunities for telehealth with the specific goals of addressing inadequate provider distribution through increased use of telehealth services to help "reduce costs, improve quality, change the conditions of practice, and improve access to health care, particularly in rural and other medically underserved areas."14 Before the California bill was passed, 12 states had already required all health benefit plans (i.e., except Medicare) to pay for covered services provided through telehealth.
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. Because Medicare beneficiaries are particularly vulnerable to these barriers, expanded use of telemedicine-based care management services offers current opportunities for improving access (Jones and Brennan, 2002; Palmas et al., 2008)
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What Services Does Medicare Pay For? · Physicians · Office of a physician · Initial inpatient consultations or follow-up inpatient · Nurse practitioners or practitioner telehealth consultations for beneficiaries in hospitals · Physician assistants · Hospitals · Office/outpatient visits, subsequent hospital care · Nurse midwives · Critical access services (1 visit every 3 days at most)
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. Notwithstanding the transportation and mobility burdens faced by many elderly and disabled beneficiaries, individuals and facilities in medically underserved metropolitan areas are not eligible for Medicare payment for telehealth services.
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. Under current payment provisions, originating sites include the office of an eligible practitioner, 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.
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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)
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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.
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From page 83... ...
It seems apparent that there are geographic pockets with persistent access and quality problems 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.
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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.
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2012b. Physician assistants: 2010-11 Occupational outlook handbook.
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Testimony to IOM Committee on Geo graphic Adjustment, Panel on Workforce, Access, and Innovation: Policy Levers for Geographic Adjustment in Medicare Payment, September. http://www.iom.edu/~/media/Files/Activity%20Files/ HealthServices/GeographicAdjustment/September%2022/Dickson.pdf (accessed July 8, 2012)
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2011. Geographic adjustment in Medicare payment: Phase I: Ensuring accuracy.
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. MedPAC (Medicare Payment Advisory Commission)
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2009. Physician assistants and nurse practitioners in specialty care: Six practices make it work.
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