Improving Access to High-Quality Care through Graduate

Haley Morin SUMR 2017 | Mentor: Dr. Matthew McHugh Haley Morin Dr. Matthew McHugh, PhD, JD, MPH, RN, CRNP, FAAN

Leonard Davis Institute SUMR Scholar 2017 The Independence Chair for Education Rising Senior, University of Pennsylvania Professor of Nursing Nursing and Healthcare Management Dual Associate Director, Center for Health Outcomes Degree Program and Policy Research Faculty Director, Nursing and Management Coordinated Dual Degree Program ROADMAP

Problem Opportunity Legislation Research Future 1

THE PROBLEM: Shortages and Maldistribution of Healthcare Providers

“ “By 2025, demand for physicians will exceed supply by a range of 46,000 to 90,000.”

-AAMC, 2015 1 - THE PROBLEM

CARE SHORTAGE

⊡ Decades of support to incentivize physicians to enter primary care ⊡ Number physicians entering primary care less than number retiring ⊡ Less than 2000 medical students a year enter primary care residencies ⊡ Number of physicians entering primary care workforce is too small to meet demand

http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Infographic.aspx 2

THE OPPORTUNITY: Advance Practice Registered Nurses 2 - THE OPPORTUNITY

HIGH QUALITY HIGH SATISFACTION ⊡ Outcomes of patients cared for by ⊡ Patients are highly satisfied with NPs are comparable to and in care provided by NPs some respects better than the care □ Horrocks, et al., 2002; Newhouse, et al., delivered by physicians 2011 □ Horrocks, et al., 2002; Kuo, Chen, ⊡ Millions of fully-insured patients Baillargeon, Raji, & Goodwin, 2015; with a choice of providers elect Mundinger et al., 2000; Newhouse, et care by NPs al., 2011; Spitzer et al., 1974 □ Dill, Pankow, Erikson, Shipman, 2013; ⊡ Chronic illness management by Druss et al., 2003 NPs is equally as effective as physician-managed care □ Horrocks, et al., 2002; Mundinger, et al., 2000; Stanik-Hutt, et al., 2013 ⊡ Preventative cancer screenings are increased with NP-provided primary care □ Mandelblatt et al., 1993 2 - THE OPPORTUNITY

COSTS ACCESS ⊡ Primary care NPs’ outcomes for ⊡ NPs are more likely than preventing hospitalizations for physicians to provide care to patients with chronic illnesses Medicaid beneficiaries and are equivalent to physicians underserved populations □ Kuo et al., 2015 □ Buerhaus, DesRoches, Dittus, & ⊡ NPs in acute care settings Donelan, 2015 decrease length of stay and ⊡ In states with full NP practice hospitalization costs and authority, appointment reduce readmissions availability for Medicaid after discharge to home patients is better and visit costs □ Collins et al., 2014; Edkins, Cairns, & are lower in primary care Hultman, 2014; Kapu, Kleinpell, & Pilon, practices with NPs 2014; Newhouse, et al., 2011 □ Richards & Polsky, 2015 □ McCauley, Bixby, & Naylor, 2006; Naylor et al., 2004 2 - THE OPPORTUNITY

IOM REPORT 2010

The totality of evidence in favor of expanding the supply of NPs led the Institute of Medicine to recommend the elimination of regulations and payment barriers to the full participation of NPs in the nation’s healthcare 2 - THE OPPORTUNITY

ISSUES AND BARRIERS

⊡ Demand for NPs is currently outstripping supply □ Adversely affecting access to healthcare ⊡ A major barrier to nursing schools producing more NPs is difficulty recruiting clinical preceptors □ Loss of productivity □ Space limitations □ Competition ⊡ Increasing difficulty of recruiting clinical preceptors ⊡ Public funding for NP education minimal □ How much money goes to GNE? □ Graduate Medical Education is roughly $9 billion a year 3

THE LEGISLATION: Graduate Nursing Education Demonstration 3 - THE LEGISLATION

GNE DEMONSTRATION

⊡ Affordable Care Act demonstration for $200 million ⊡ Primary intervention □ Provider payment incentive through provider organizations □ Financed by Medicare payments same way as residency programs □ Pays for clinical training costs of NPs ⊡ Must have at least 50% of the demonstration supporting clinical training in primary care ⊡ Five hospital sites selected through competitive application process □ 4 year demonstration program (extended one year) □ Schools attached to /health systems 3 - THE LEGISLATION

DEMONSTRATION SITES

⊡ Hospital of University of Pennsylvania, Philadelphia PA ⊡ Memorial Hermann-Texas Medical Center, Houston TX ⊡ Honor Health for the State of Arizona, Scottsdale, AZ ⊡ Rush University Medical Center, Chicago, IL ⊡ Duke University Health System Durham, NC 4

THE RESEARCH: Evaluation of GNE Demonstration 4 - THE RESEARCH

OBJECTIVE Exploit opportunity created by $200 million GNE demonstration to determine whether Medicare payments to hospitals and community organizations is associated with: ⊡ Substantial overall increases in NP enrollments and graduations ⊡ Substantial increases in student enrollments and graduations in primary care 4 - THE RESEARCH

GNE non-GNE 4 - THE RESEARCH

GNE

non-GNE 4 - THE RESEARCH

DATA ANALYSIS

⊡ R and STATA □ Merge, merge, merge □ MatchMutli package in R ⊡ Multivariate match □ Want close balance in characteristics between non-GNE sites and GNE sites □ Balance assessed using standardized differences in means, histograms, jitter plots 4 - THE RESEARCH

MATCHING VARIABLES

⊡ Preceptor market competition □ Hospital discharge volume □ Market share using DOJ definitions of market concentration □ Acute care beds, primary care physicians, outpatient visits, FQHC ⊡ market competition □ Nursing school graduate volume for NPs and RNs □ Related market indicators such as RN and NP per 100,000 residents ⊡ Demographic composition □ Population, rural/urban, racial demographics, poverty, health profession shortage ⊡ Outcomes □ Enrollments and graduations in baseline □ Nurse practitioners, nurse midwives, clinical nurse specialists, nurse anesthetists 5

THE FUTURE: Policy Implication and the Future of Healthcare 5 - THE FUTURE

POLICY IMPLICATIONS

⊡ Evaluation can help make the case for continued GNE funding ⊡ Production of more NPs? ⊡ Improved cost, quality, and access in primary care and beyond

LESSONS LEARNED

⊡ You can teach yourself anything on YouTube ⊡ Working with data can be tedious ⊡ Timelines are sometimes out of your control THANKS!

Any questions?

Thank you to Dr. McHugh, Joanne Levy, Safa Browne, Hoag Levins, Kathryn Lee, and Joshua Dahlerbruch

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