1. Access to Care and Coverage Group 1

2. Public Policy Problem Problem: Need to Enhance Patient Access to the Continuum of Healthcare in Underserved Areas

3. Dimensions of Access Availability –Supply & Demand Mismatch –Rural & Urban Accessibility –Geography, Infrastructure, Transportation Accommodation –Ability to accept patients when they need to be seen –Communication – email, phone Affordability –Lack of Insurance –Underinsured Acceptability –Cultural Barriers and Preferences The Concept of Access: Definition and Relationship to Consumer Satisfaction Penchansky, R, Thomas JW. Medical Care 1981.

4. Rationale Many Americans can’t get the healthcare that they need when they need it Many Americans live in areas where there are too few healthcare providers Provider availability limits access to the continuum of healthcare in areas where demand exceeds supply

5. Stakeholders - Supporters Providers –AAMC –AH(osp)A –ACP –NMA –AAP Patient Advocacy Groups –AARP –ADA –AH(eart)A –ACS –Urban League Business Orgs –Ranchers –Miners –Farmers –PhRMA –Chamber of Commerce Governors Quality Groups –NCQA, NQF –Bridges to Excellence –Leap Frog

6. Stakeholders Undetermined Support –Provider Groups AAP NP/PA Orgs ACOG NAACP AAFP ACEP –Payors –Fiscal Conservatives –Unions Opposed –Subspecialty societies –AMA

7. Plan of Action Align financial incentives to expand availability to provider services Revise the Resource Based Relative Value Scale (RBRVS) to correct the supply-demand mismatch Require AHRQ to specify a supply & demand adjustment factor Simulate the impact of the revision on healthcare access and provider income

8. Supply-Demand Factor RBRVS = Current = Work * Cost of Living Adjustment Revised = Work * Cost of Living Adjustment * supply/demand factor

9. Key Players Provider trade associations Payors Patient Advocacy Groups

10. Projecting Fiscal Impact Federal approach that is budget neutral –Increased reimbursement to undersupplied areas will be offset by adjusting reimbursement in oversupplied areas Pre-implementation simulations can confirm budget neutrality

12. Outcome Statement - Access Improve Patient Access to the Continuum of Healthcare Providers in Underserved Areas

13. Components Access to Care & Coverage Uninsurance –Medicaid vs continuum of coverage –Spectrum of Coverage –Under-insurance related to type of service –Ambulatory care not-well reimbursed –Rationing vs. Cost sharing Geography Temporal –Hospital vs. Patient –Patient Provider Time Mismatch Cultural –Language –Trust –Perception of Organized Medicine –Education for Appropriateness of Care Societal Preference Choice Education / Access to Information –Empowered Patients –Shared Medical Records Provider Knowledge & Practices –Lack of Understanding –Need aligned incentives Access to Physicians Costs / Cost Sharing –Price vs Quality Age –Drives Uninsurance / Coverage Gap Locus of Control Type of Care –Specialty vs Primary Care Payor –Compete for insured –Cost Sharing –Provider incentive/ dis-incentive –System Level –Provider vs Patient –Liability Limiting Services Incentives –Perceptions of Quality / Need –Education / implementation in multicultural society Tort Reform –State level interventions vs.Federal laws Other Models

14. A Small Steps Towards Universal Access Resource-Based Relative Value Scale –Pilot to Change Reimbursement –Add modifier for Appropriateness Disease Base vs. Population Based Medication Side – Used the right visit RVU Multiplier Pay Patient Directly –Disease Targets: Depression, Diabetes, CHF, CAD Measurable Outcomes Evidence Base for Effectiveness Active Constituency Follow Along Disease Continuum How to Change Reimbursement Scale –CMS Authority Can Change Incentives Can Change Payment Scales Can Not Reduce Benefits for Beneficiaries –CMS Demonstration Projects / Waiver Mechanism – Not Congress –Medicaid Patient and Provider Both Aligned in Incentive

15. What Do We Want to Do? Changes in Delivery System –Include Insured vs. all –Alignment of costs / incentives Change one incentive that will affect access Mass. Model –Problems Budget Insurance Not willing to Pay Insufficient Provider Mix Change Frame of Access from Patient to Service Level –Patient Based Incentive –Costs Savings results