Identification of Surgeon Outliers to Improve Cost Efficiency: A Novel Use of the Centers for Medicare and Medicaid Quality Payment Program.

BACKGROUND: Bundled payment programs for total joint arthroplasty (TJA) have become popular among both private and public payers. Because these programs provide surgeons with financial incentives to decrease costs through reconciliation payments, there is an advantage to identifying and emulating cost-efficient surgeons. The objective of this study was to utilize the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) in combination with institutional data to identify cost-efficient surgeons within our region and, subsequently, identify cost-saving practice patterns. METHODS: Data was obtained from the CMS QPP for total knee arthroplasty (TKA) and total hip arthroplasty (THA) surgeons within a large metropolitan area from January 2019 to December 2021. A simple linear regression determined the relationship between surgical volume and cost-efficiency. Internal practice financial data determined whether patients of identified surgeons differed with respect to x-ray visits, physical therapy visits, out-of-pocket payments to the practice, and whether surgery was done in hospital or surgical center settings. RESULTS: There were 4 TKA and 3 THA surgeons who were cost-efficiency outliers within our area. Outliers and nonoutlier surgeons had patients who had similar body mass index, American Society of Anesthesiologists Physical Status Score, and age-adjusted Charlson Comorbidity Index scores. Patients of these surgeons had fewer x-ray visits for both TKA and THA (1.06 versus 1.11, P < .001; 0.94 versus 1.15, P < .001) and lower out-of-pocket costs ($86.10 versus $135.46, P < .001; $116.10 versus $177.40, P < .001). If all surgeons performing > 30 CMS cases annually within our practice achieved similar cost-efficiency, the savings to CMS would be $17.2 million for TKA alone ($75,802,705 versus $93,028,477). CONCLUSIONS: The CMS QPP can be used to identify surgeons who perform cost-efficient surgeries. Practice patterns that result in cost savings can be emulated to decrease the cost curve, resulting in reconciliation payments to surgeons and institutions and cost savings to CMS.

Surgical Episodes of Care for Price Transparency Using the Episode Grouper for Medicare.

OBJECTIVE: To explore the use of an episode grouper to more accurately identify the complete set of surgical services typically provided in a surgical episode of care and the corresponding range of prices, using colectomy for cancer as the example. BACKGROUND: Price transparency is an important policy issue that will require surgeons to better understand the components and cost of care. METHODS: This study uses the Episode Grouper for Medicare business logic to construct colectomy surgical episodes of care for cancer using Medicare claims data for the Boston Hospital Referral Region from 2012 to 2015. Descriptive statistics show the mean reimbursement based on patient severity and stage of surgery, along with the number of unique clinicians billing for care and the mix of services provided. RESULTS: The Episode Grouper for Medicare episode grouper identified 3182 colectomies in Boston between 2012 and 2015, with 1607 done for cancer. The mean Medicare allowed amount per case is $29,954 and varies from $26,605 to $36,850 as you move from low to high-severity cases. The intrafacility stage is the most expensive ($23,175 on average) compared with the pre ($780) and post ($6,479) facility stages. There is tremendous heterogeneity in the service mix. CONCLUSIONS: Episode groupers are a potentially valuable tool for identifying variations in service mix and teaming patterns that correlate with a total price. By looking at patient care holistically, stakeholders can identify opportunities for price transparency and care redesign that have heretofore been hidden.

Estimating the Primary Care Workforce for Medicare Beneficiaries Using an Activity-Based Approach.

BACKGROUND: The enumeration of the primary care workforce relies on potentially inaccurate specialty designations sourced from licensure registries and clinician surveys. OBJECTIVE: To use an activity-based measure of primary care to estimate the number of physicians, nurse practitioners (NPs), and physician assistants (PAs) providing primary care to Medicare beneficiaries. DESIGN: Observational study using Medicare fee-for-service (FFS) claims data. SUBJECTS: All clinicians in the US billing Medicare in 2019 and their fee-for-service Medicare patients. MAIN MEASURES: We construct three measures that together distinguish primary care from specialty clinicians: (1) presence of evaluation and management (E&M) services in a setting consistent with primary care, (2) the dispersion of clinical care across International Classification of Diseases-10 (ICD-10) chapters, and (3) the extent of provided services that are atypical of primary care (e.g., surgical procedure). We apply parameters to the measures to identify the clinicians likely providing primary care and compare the resulting classifications across provider type. KEY RESULTS: Of physicians with at least 50 Medicare beneficiaries, 19-22% provide primary care. Of medical generalists (i.e., family medicine, internal medicine) with at least 50 beneficiaries, 61-68% provide primary care. We estimate that 40-45% of NPs and 27-30% of PAs meeting the panel size threshold are primary care providers in FFS Medicare. CONCLUSIONS: Our findings suggest that based on a primary care practice style, the number of primary care physicians in FFS Medicare is likely smaller than conventional estimates. However, compared to prior estimates, the number of primary care NPs is larger and the number of PAs is similar.

Challenges in predicting future high-cost patients for care management interventions.

BACKGROUND: To test the accuracy of a segmentation approach using claims data to predict Medicare beneficiaries most likely to be hospitalized in a subsequent year. METHODS: This article uses a 100-percent sample of Medicare beneficiaries from 2017 to 2018. This analysis is designed to illustrate the actuarial limitations of person-centered risk segmentation by looking at the number and rate of hospitalizations for progressively narrower segments of heart failure patients and a national fee-for-service comparison group. Cohorts are defined using 2017 data and then 2018 hospitalization rates are shown graphically. RESULTS: As the segments get narrower, the 2018 hospitalization rates increased, but the percentage of total Medicare FFS hospitalizations accounted for went down. In all three segments and the total Medicare FFS population, more than half of all patients did not have a hospitalization in 2018. CONCLUSIONS: With the difficulty of identifying future high utilizing beneficiaries, health systems should consider the addition of clinician input and 'light touch' monitoring activities to improve the prediction of high-need, high-cost cohorts. It may also be beneficial to develop systemic strategies to manage utilization and steer beneficiaries to efficient providers rather than targeting individual patients.

State Variation in the Utilization of Nurse Practitioner-Provided Home-Based Primary Care: A Medicare Claims Analysis.

Nurse practitioners (NPs) provide an increasing proportion of home-based primary care, despite restrictive scope of practice laws in approximately one half of states. We examined the relationship between scope of practice laws and state volume of NP-provided home-based primary care by performing an analysis of 2018 to 2019 Medicare claims. For each state we calculated the proportion of total home-based primary care visits by NPs and the proportion of all NPs providing home-based primary care. We used the 2018 American Association of Nurse Practitioners classification of state practice environment. We performed chi-square tests to assess the significance between volume and practice environment. We found that 42% of home-based primary care is delivered by NPs nationally, but substantial variation exists across states. We did not find a discernible or statistically significant pattern of uptake of NP-provided home-based primary care across full, reduced, or restricted states. [Journal of Gerontological Nursing, 49(5), 11-17.].

Primary Care Nurse Practitioner Work Environments and Hospitalizations and ED Use Among Chronically Ill Medicare Beneficiaries.

BACKGROUND: Nurse practitioners (NPs) play a critical role in delivering primary care, particularly to chronically ill elderly. Yet, many NPs practice in poor work environments which may affect patient outcomes. OBJECTIVE: We investigated the relationship between NP work environments in primary care practices and hospitalizations and emergency department (ED) use among chronically ill elderly. RESEARCH DESIGN: We used a cross-sectional design to collect survey data from NPs about their practices. The survey data were merged with Medicare claims data. SUBJECTS: In total, 979 primary care practices employing NPs and delivering care to chronically ill Medicare beneficiaries (n=452,931) from 6 US states were included. MEASURES: NPs completed the Nurse Practitioner-Primary Care Organizational Climate Questionnaire-a valid and reliable measure for work environment. Data on hospitalizations and ED use was obtained from Medicare claims. We used Cox regression models to estimate risk ratios. RESULTS: After controlling for covariates, we found statistically significant associations between practice-level NP work environment and 3 outcomes: Ambulatory Care Sensitive (ACS) ED visits, all-cause ED visits, and all-cause hospitalizations. With a 1-unit increase in the work environment score, the risk of an ACS-ED visit decreased by 4.4% [risk ratio (RR)=0.956; 99% confidence interval (CI): 0.918-0.995; P=0.004], an ED visit by 3.5% (RR=0.965; 99% CI: 0.933-0.997; P=0.005), and a hospitalization by 4.0% (RR=0.960;99% CI: 0.928-0.993; P=0.002). There was no relationship between NP work environment and ACS hospitalizations. CONCLUSION: Favorable NP work environments are associated with lower hospital and ED utilization. Practice managers should focus on NP work environments in quality improvement strategies.

Rural-urban prescribing patterns by primary care and behavioral health providers in older adults with serious mental illness.

BACKGROUND: Older adults with serious mental illness (SMI) often have multiple comorbidities and complex medication schedules. Shortages of behavioral health specialists (BHSs), especially in rural areas, frequently make primary care providers (PCPs) the only clinician managing this complex population. The aim of this study was to describe rural/urban psychiatric medication prescribing in older adults with SMI by PCPs and BHSs, and by clinician type. METHODS: This retrospective descriptive analysis used 2018 Medicare data to identify individuals with a bipolar, major depression, schizophrenia, or psychosis diagnosis and examined medication claims for antianxiety, antidepressants, antipsychotics, hypnotics, and anticonvulsants. Descriptive statistics summarized percentage of medications provided by PCPs and BHSs stratified by rural and urban areas and by drug class. Additional analyses compared psychiatric prescribing patterns by physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs). RESULTS: In urban areas, PCPs prescribed at least 50% of each psychiatric medication class, except antipsychotics, which was 45.2%. BHSs prescribed 40.7% of antipsychotics and less than 25% of all other classes. In rural areas, percentages of psychiatric medications from PCPs were over 70% for each medication class, except antipsychotics, which was 60.1%. Primary care physicians provided most psychiatric medications, between 36%-57% in urban areas and 47%-65% in rural areas. Primary care APRNs provided up to 13% of prescriptions in rural areas, which was more than the amount prescribed by BHS physicians, expect for antipsychotics. Psychiatric mental health APRNs provided up to 7.5% of antipsychotics in rural areas, but their prescribing contribution among other classes ranged between 1.1%-3.6%. PAs provided 2.5%-3.4% of medications in urban areas and this increased to 3.9%-5.1% in rural areas. CONCLUSIONS: Results highlight the extensive roles of PCPs, including APRNs, in managing psychiatric medications for older adults with SMI.

The Effect of Supervision Waivers on Practice: A Survey of Massachusetts Nurse Practitioners During the COVID-19 Pandemic.

BACKGROUND: While optimal utilization of the nurse practitioner (NP) workforce is an increasingly popular proposal to alleviate the growing primary care shortage, federal, state, and organizational scope of practice policies inhibit NPs from practicing to the full extent of their license and training. In March of 2020, NP state-specific supervisory requirements were temporarily waived to meet the demands of the coronavirus disease 2019 (COVID-19) pandemic in Massachusetts. OBJECTIVE: The objective of this study was to examine the impact of temporarily waived state practice restrictions on NP perception of care delivery during the initial surge of the COVID-19 pandemic in Massachusetts. RESEARCH DESIGN: Mixed methods descriptive analysis of a web-based survey of Massachusetts NPs (N=391), conducted in May and June 2020. RESULTS: The vast majority (75%) of NPs believed the temporary removal of practice restriction did not perceptibly improve clinical work. Psychiatric mental health NPs were significantly more likely than other NP specialties to believe the waiver improved clinical work (odds ratio=6.68, P=0.001). NPs that experienced an increase in working hours during the pandemic surge were also more likely to report a positive effect of the waiver (odds ratio=2.56, P=0.000). CONCLUSIONS: Temporary removal of state-level practice barriers alone is not sufficient to achieve immediate full scope of practice for NPs. The successful implementation of modernized scope of practice laws may require a collective effort to revise organizational and payer policies accordingly.

Drivers of Cost Differences Between Nurse Practitioner and Physician Attributed Medicare Beneficiaries.

BACKGROUND: Although recent research suggests that primary care provided by nurse practitioners costs less than primary care provided by physicians, little is known about underlying drivers of these cost differences. RESEARCH OBJECTIVE: Identify the drivers of cost differences between Medicare beneficiaries attributed to primary care nurse practitioners (PCNPs) and primary care physicians (PCMDs). STUDY DESIGN: Cross-sectional cost decomposition analysis using 2009-2010 Medicare administrative claims for beneficiaries attributed to PCNPs and PCMDs with risk stratification to control for beneficiary severity. Cost differences between PCNPs and PCMDs were decomposed into payment, service volume, and service mix within low-risk, moderate-risk and high-risk strata. RESULTS: Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum. In the low-risk stratum, the difference is comprised of 24% service volume, 6% payment, and 4% service mix. In the high-risk stratum, the difference is composed of 7% service volume, 9% payment, and 4% service mix. The cost difference between PCNP and PCMD attributed beneficiaries is persistent and significant, but narrows as risk increases. Across the strata, PCNPs use fewer and less expensive services than PCMDs. In the low-risk stratum, PCNPs use markedly fewer services than PCMDs. CONCLUSIONS: There are differences in the costs of primary care of Medicare beneficiaries provided by nurse practitioners and MDs. Especially in low-risk populations, the lower cost of PCNP provided care is primarily driven by lower service volume.

National Quality Forum Guidelines for Evaluating the Scientific Acceptability of Risk-adjusted Clinical Outcome Measures: A Report From the National Quality Forum Scientific Methods Panel.

: Quality measurement is at the heart of efforts to achieve high-quality surgical and medical care at a lower cost. Without accurate quality measures, it is not possible to appropriately align incentives with quality. The aim of these National Quality Forum (NQF) guidelines is to provide measure developers and other stakeholders with guidance on the standards used by the NQF to evaluate the scientific acceptability of performance measures. Using a methodologically rigorous and transparent process for evaluating health care quality measures is the best insurance that alternative payment plans will truly reward and promote higher quality care. Performance measures need to be credible in order for physicians and hospitals to willingly partner with payers in efforts to improve population outcomes. Our goal in creating this position paper is to promote the transparency of NQF evaluations, improve the quality of performance measurements, and engage surgeons and all other stakeholders to work together to advance the science of performance measurement.

Opioid-prescribing Outcomes of Medicare Beneficiaries Managed by Nurse Practitioners and Physicians.

BACKGROUND: Primary care providers are at the center of the opioid epidemic. Whether nurse practitioners (NPs) have different opioid-prescribing outcomes from physicians is not known. OBJECTIVE: To examine opioid-prescribing outcomes of Medicare beneficiaries receiving care from NPs and physicians in primary care. RESEARCH DESIGN: We used Medicare data from 2009 to 2013 and a propensity score-weighted analysis. SUBJECTS: Beneficiaries residing in states in which NPs are able to prescribe controlled substances without physician oversight and who did not have a cancer diagnosis, hospice care, or end-stage renal disease. MEASURES: First, we measured whether beneficiaries received any opioid prescription. Second, for beneficiaries who received opioids, we measured acute (<90 d supply) and chronic (≥90 d supply) use at baseline (2009-2010) and follow-up (2012-2013). Third, we measured potential misuse of opioid prescribing using a daily morphine milligram equivalent dose of >100 mg, overlapping prescriptions of opioids >7 days, and overlapping prescriptions of opioids with benzodiazepines >7 days. RESULTS: Beneficiaries managed by NPs were less likely to receive an opioid [odds ratio (OR), 0.87; P<0.001], were less likely to be acute users at baseline (OR, 0.84; P<0.001), and were more likely to receive a high daily opioid dose of morphine milligram equivalent >100 mg compared with physician-managed beneficiaries (OR, 1.11; P=0.048). CONCLUSIONS: Findings suggest educational programs and clinical guidelines may require approaches tailored to different providers. Future research should examine the contributing factors of these patterns to ensure high-quality pain management and guide policy makers on NP-controlled substance-prescribing regulations.

The Rehabilitation Enhancing Aging Through Connected Health Prehabilitation Trial.

OBJECTIVE: To evaluate the proof of concept of an innovative model of physical therapy Rehabilitation Enhancing Aging through Connected Health (REACH) and evaluated its feasibility and effect on physical function and health care utilization. DESIGN: Quasi-experimental 12-month clinical trial. SETTING: Two outpatient rehabilitation centers. PARTICIPANTS: Community-dwelling older primary care patients with a treatment arm undergoing the intervention (n=75; mean age=77±5.9y; 54% women) and propensity matched controls derived from a longitudinal cohort study (n=430; mean age=71±7.0y; 68% women) using identical recruitment criteria (N=505). INTERVENTION: Combined outpatient and home PT augmented with a commercially available app and computer tablet. MEASUREMENTS: Primary outcomes included a feasibility questionnaire, exercise adherence, self-reported function, and the Short Physical Performance Battery (SPPB). Secondary outcomes included the rates of emergency department (ED) visits and hospitalizations. RESULTS: Among REACH participants, we observed a 9% dropout rate. After accounting for dropouts, with propensity matching, n=68 treatments and n=100 controls were analyzed. Over the 12-month study duration, 85% of participants adhered to the exercise program an average of 2 times a week and evaluated the treatment experience favorably. In comparison to controls, after 1 year of treatment and within multivariable regression models, REACH participants did not manifest a significant difference in patient reported function (group x time effect 1.67 units, P=.10) but did manifest significant differences in SPPB (group x time effect 0.69 units, P=.03) and gait speed (group x time effect .08m/s, P=.02). In comparison to controls, after 1 year, the rate of ED visits (group x time treatment rate=0.27, P<.004) were significantly reduced, but a significant reduction in hospitalizations was not observed. CONCLUSION: The REACH intervention is feasible and has proof of concept in preventing functional decline and favorably affecting health care utilization. Evaluation on a larger scale is warranted.

Comparing the rates of low-value back images ordered by physicians and nurse practitioners for Medicare beneficiaries in primary care.

BACKGROUND: Little is known about the extent of ordering low-value services by. PURPOSE: To compare the rates of low-value back images ordered by primary care physicians (PCMDs) and primary care nurse practitioners (PCNPs). METHOD: We used 2012 and 2013 Medicare Part B claims for all beneficiaries in 18 hospital referral ̱regions (HRRs) and a measure of low-value back imaging from Choosing Wisely. Models included random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician sex, the emergency department setting, back pain visit volume, organization, and region (HRR). FINDINGS: PCNPs (N = 231) and PCMDs (N = 4,779) order low-value back images at similar rates (NP: all images: 26.5%; MRI/CT: 8.4%; MD: all images: 24.5%; MRI/CT: 7.7%), with no detectable significant difference when controlling for covariates. DISCUSSION: PCNPs and PCMDs order low-value back images at an effectively similar rate.

Quality of Primary Care Provided to Medicare Beneficiaries by Nurse Practitioners and Physicians.

OBJECTIVE: To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians. DATA SOURCES: Medicare part A and part B claims during 2012-2013. STUDY DESIGN: Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening. EXTRACTION METHODS: Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians. PRINCIPAL FINDINGS: Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening. CONCLUSIONS: The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.

Geographic Region and Profit Status Drive Variation in Hospital Readmission Outcomes Among Inpatient Rehabilitation Facilities in the United States.

OBJECTIVE: To examine whether there are differences in inpatient rehabilitation facilities' (IRFs') all-cause 30-day postdischarge hospital readmission rates vary by organizational characteristics and geographic regions. DESIGN: Observational study. SETTING: IRFs. PARTICIPANTS: Medicare fee-for-service beneficiaries discharged from all IRFs nationally in 2013 and 2014 (N = 1166 IRFs). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We applied specifications for an existing quality measure adopted by Centers for Medicare & Medicaid Services for public reporting that assesses all-cause unplanned hospital readmission measure for 30 days postdischarge from inpatient rehabilitation. We estimated facility-level observed and risk-standardized readmission rates and then examined variation by several organizational characteristics (facility type, profit status, teaching status, proportion of low-income patients, size) and geographic factors (rural/urban, census division, state). RESULTS: IRFs' mean risk-standardized hospital readmission rate was 13.00%±0.77%. After controlling for organizational characteristics and practice patterns, we found substantial variation in IRFs' readmission rates: for-profit IRFs had significantly higher readmission rates than did not-for-profit IRFs (P<.001). We also found geographic variation: IRFs in the South Atlantic and South Central census regions had the highest hospital readmission rates than did IRFs in New England that had the lowest rates. CONCLUSIONS: Our findings point to variation in quality of care as measured by risk-standardized hospital readmission rates after IRF discharge. Thus, monitoring of readmission outcomes is important to encourage quality improvement in discharge care planning, care transitions, and follow-up.

How important is social support in determining patients' suitability for transplantation? Results from a National Survey of Transplant Clinicians.

BACKGROUND: National guidelines require programmes use subjective assessments of social support when determining transplant suitability, despite limited evidence linking it to outcomes. We examined how transplant providers weigh the importance of social support for kidney transplantation compared with other factors, and variation by clinical role and personal beliefs. METHODS: The National survey of the American Society of Transplant Surgeons and the Society of Transplant Social Work in 2016. Using a discrete choice approach, respondents compared two hypothetical patient profiles and selected one for transplantation. Conditional logistic regression estimated the relative importance of each factor; results were stratified by clinical role (psychosocial vs medical/surgical providers) and beliefs (outcomes vs equity). RESULTS: Five hundred and eighy-four transplant providers completed the survey. Social support was the second most influential factor among transplant providers. Providers were most likely to choose a candidate who had social support (OR=1.68, 95% CI 1.50 to 1.86), always adhered to a medical regimen (OR=1.64, 95% CI 1.46 to 1.88), and had a 15 years life expectancy with transplant (OR=1.61, 95% CI 1.42 to 1.85). Psychosocial providers were more influenced by adherence and quality of life compared with medical/surgical providers, who were more influenced by candidates' life expectancy with transplant (p<0.05). For providers concerned with avoiding organ waste, social support was the most influential factor, while it was the least influential for clinicians concerned with fairness (p<0.05). CONCLUSIONS: Social support is highly influential in listing decisions and may exacerbate transplant disparities. Providers' beliefs and reliance on social support in determining suitability vary considerably, raising concerns about transparency and justice.

The rehabilitation enhancing aging through connected health (REACH) study: study protocol for a quasi-experimental clinical trial.

BACKGROUND: Mobility limitations among older adults increase the risk for disability and healthcare utilization. Rehabilitative care is identified as the most efficacious treatment for maintaining physical function. However, there is insufficient evidence identifying a healthcare model that targets prevention of mobility decline among older adults. The objective of this study is to evaluate the preliminary effectiveness of a physical therapy program, augmented with mobile tele-health technology, on mobility function and healthcare utilization among older adults. METHODS: This is a quasi-experimental 12-month clinical trial conducted within a metropolitan-based healthcare system in the northeastern United States. It is in parallel with an existing longitudinal cohort study evaluating mobility decline among community-dwelling older adult primary care patients over one year. Seventy-five older adults (≥ 65-95 years) are being recruited using identical inclusion/exclusion criteria to the cohort study. Three aims will be evaluated: the effect of our program on 1) physical function, 2) healthcare utilization, and 3) healthcare costs. Changes in patient-reported function over 1 year in those receiving the intervention (aim 1) will be compared to propensity score matched controls (N = 150) from the cohort study. For aims 2 and 3, propensity scores, derived from logistic regression model that includes demographic and diagnostic information available through claims and enrollment information, will be used to match treatment and control patients in a ratio of 1:2 or 1:3 from a Medicare Claims Registry derived from the same geographic region. The intervention consists of a one-year physical therapy program that is divided between a combination of outpatient and home visits (6-10 total visits) and is augmented on a computerized tablet using of a commercially available application to deliver a progressive home-based exercise program emphasizing lower-extremity function and a walking program. DISCUSSION: Incorporating mobile health into current healthcare models of rehabilitative care has the potential to decrease hospital visits and provide a longer duration of care. If the hypotheses are supported and demonstrate improved mobility and reduced healthcare utilization, this innovative care model would be applicable for optimizing the maintenance of functional independence among community-dwelling older adults. TRIAL REGISTRATION: ClinicalTrial.gov Identifier: NCT02580409 (Date of registration October 14, 2015).

The quality of primary care provided by nurse practitioners to vulnerable Medicare beneficiaries.

BACKGROUND: Studies suggest nurse practitioners are heavily represented among primary care providers for vulnerable Medicare beneficiaries. PURPOSE: The purpose of this study was to compare quality indicators among three groups of vulnerable beneficiaries managed by MDs and nurse practitioners (NPs). METHODS: The methods include retrospective cohort design examining 2012 and 2013 Medicare claims for three beneficiary groups: (a) initially qualified for the program due to disability, (b) dually eligible for Medicare and Medicaid, and (c) both disabled and dually eligible. Validated quality indicators in four domains were analyzed. DISCUSSION: Gaps in outcomes suggest better performance for primary care nurse practitioners (PCNPs) in preventable hospitalizations and adverse outcomes. Outcome gaps suggesting better performance for primary care physicians in chronic disease management were diminished for beneficiaries who were both disabled and dually eligible suggesting improved performance for PCNPs within this subpopulation. CONCLUSION: These findings add new evidence indicating the quality of primary care provided to vulnerable Medicare beneficiaries by PCNPs is generally consistent with clinical guidelines and the less intensive use of costly health care services.

Role of Geography and Nurse Practitioner Scope-of-Practice in Efforts to Expand Primary Care System Capacity: Health Reform and the Primary Care Workforce.

BACKGROUND: Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians--particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured. OBJECTIVE: We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws. RESEARCH DESIGN: An observational study. SUBJECTS: 2013 Area Health Resource File (AHRF) and US Census Bureau county travel data. MEASURES: The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC. RESULTS: We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations. CONCLUSIONS: Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.