Geographic Adjustment in Medicare Payment Phase II: Implications for Access, Quality, and Efficiency (2012) / Chapter Skim
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Summary: Implications of Geographic Adjustment for Access, Quality, and Efficiency of Care
Summary: Implications of Geographic Adjustment for Access, Quality, and Efficiency of Care
Pages 1-12
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These changes include the use of one set of payment areas and one source of wage and benefits data for hospitals and practitioners; expanding the range of occupations used in making the geographic adjustments for employee compensation; and developing a new empirical model for adjusting practitioner payment. The report concluded that its recommendations, if implemented, would substantially improve the accuracy of Medicare's geographic payment adjustments and render unnecessary the many exceptions and reclassifications that exist in the current payment system.
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health care marketplace, the committee will also evaluate and consider · T he effect of the adjustment factors on the level and distribution of the health care workforce and resources, including Recruitment and retention, taking into account mobility between metropolitan and nonmetropolitan areas; Ability of hospitals and other facilities to maintain an adequate and skilled work force; and Patient access to providers and needed medical technologies; · The effect of adjustment factors on population health and quality of care; and · The effect of the adjustment factors on the ability of providers to furnish efficient, high-value care. A first report will address the issues surrounding the adjustment factors themselves, and then a second report that evaluates the possible effects of the adjustment factors will follow.
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For purposes of the simulations, the committee used the definition of geographically based HPSAs for primary care services, as adopted by CMS for purposes of implementing the primary care bonus payment program initiated under the Affordable Care Act.2 Health professionals eligible for primary care bonus payments include physicians in general internal medicine, family practice, pediatrics, and geriatrics, as well as nurse practitioners (NPs) and physician assistants 1 Health Professional Shortage Areas are an administrative designation by the Health Resources and Services Admin istration that identify areas with a low or insufficient primary care workforce (http://bhpr.hrsa.gov/shortage)
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Key Findings from Hospital Payment Simulations 1.As a result of moving to a more technically accurate wage index, the change in payments would be between 5 and +5 percent for discharges in 88 percent of hospitals. 2.The most substantial differences in payments under the index as recommended by the committee as compared to payments under current CMS policy are the result of eliminating policy adjustments, such as the various exceptions, market reclassifications, and floors, rather than the result of technical corrections to improve accuracy.
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EVIDENCE OF GEOGRAPHIC VARIATION IN ACCESS, QUALITY, AND WORKFORCE DISTRIBUTION The statement of task called for the committee to "evaluate and consider" the effects of the geographic adjustment factors on access, quality, and workforce distribution. 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, and then considered how Medicare and other payment policies might improve access for beneficiaries based on the evidence they found.
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However, the variations do not appear to be strongly related to differences in or potential changes to feefor-service payment. Workforce Distribution and Supply The committee was also asked to consider the "level and distribution of the health care workforce and resources, including mobility between metropolitan and nonmetropolitan areas." The health care workforce is unevenly distributed across the country, as are Medicare beneficiaries themselves.3 More than half of Medicare beneficiaries have one or more chronic conditions, such as diabetes, hypertension, and kidney disease, and their care often requires a combination of primary care and specialty services from multiple clinicians.
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Due primarily to limitations in data, the committee's assessment of workforce supply and distribution of health care services was focused on primary care physicians, general surgeons, nurses, nurse practitioners, and physician assistants. The committee documented geographic variation in the practice locations for certain primary care practitioners; for example, nurse practitioners are more likely than physicians to provide primary care services and to choose to practice in shortage areas.
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An increasing body of evidence shows that telemedicine or telehealth care management of beneficiaries with chronic diseases, such as diabetes and congestive heart failure, can help reduce preventable rehospitalizations and reduce access barriers related to geographic distance, weather, disability, lack of transportation, or shortages of practitioners in rural areas and other medically underserved urban areas. Scope of Practice Traditionally, discussions of workforce and 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.
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For example, remote patient monitoring, in which electronic devices are used to remotely collect and send real-time personal health information to a clinician, is emerging as a standard of care that improves access and clinical efficiencies and reduces the travel burden on beneficiaries. Currently, Medicare pays for telehealth services when provided by qualified providers to beneficiaries in rural areas, but individuals and facilities in medically underserved metropolitan areas are not eligible for Medicare payment for telehealth services.
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RECOMMENDATION 4: The Medicare program should reexamine its policies that provide location-based adjustments for specific groups of hospitals, and modify or discontinue them based on their effectiveness in ensuring adequate access to appropriate care. Several groups of hospitals currently receive special treatment in determining Medicare payment, on the basis that extra payment is necessary to preserve beneficiaries' access to appropriate care in the areas they serve: critical access hospitals, sole community hospitals, Medicare-dependent hospitals, low-volume hospitals, and rural referral centers.
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RECOMMENDATION 6: Federal support should facilitate independent external evaluations of ongoing workforce programs intended to provide access to adequate health services for underserved populations and Medicare beneficiaries. These programs include the National Health Service Corps, Title VII and VIII programs under the Public Health Service Act, and related programs intended to achieve those goals.
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