兰德-Evaluation-of-Policy-Options-for-Increasing-the-Availability-of-Primary-Care-Services-in-Rural-Washington-State_139页_2mb

Summary of the Research Report: Evaluation of Policy Options for Increasing the Availability of Primary Care Services in Rural Washington State

Purpose

This report evaluates several policy options aimed at addressing the perceived shortage of primary care physicians in rural Washington State. The Washington State Institute for Public Policy commissioned the RAND Corporation to project the effects of these policies on the rural primary care workforce through 2025. The policy options include:

• Opening the Elson S. Floyd College of Medicine at Washington State University (WSU) in 2017
• Increasing the number of primary care residency positions
• Expanding educational loan-repayment incentives
• Increasing Medicaid payment rates for primary care physicians
• Encouraging the adoption of alternative primary care models, such as medical homes and nurse-managed health centers (NMHCs)

Methods

The study used a combination of qualitative and quantitative methods:

• Key-informant interviews: Conducted with 39 experts from various sectors including government, medical institutions, and rural hospitals to identify and validate policy options.
• Logic model: Developed to illustrate the relationships between factors influencing the supply of primary care physicians and services.
• Empirical models: Three types of models were used:
  • Predictive models based on national data to forecast changes in the primary care workforce.
  • Inferential models to estimate the effects of policy options on the workforce.
  • Microsimulation model to assess the impact of Medicaid payment rate changes.
• Previously published estimates were used to analyze the effects of new care-delivery models.

Key Findings

Primary Care Shortage Trends

• The number of primary care physicians per 100,000 population is projected to decline in both rural and urban areas of Washington State by 2025.
• Rural areas are expected to see a decline of 3.66 physicians per 100,000 population (a 7% reduction from 2013 levels).
• Urban areas are expected to see a decline of 4.14 physicians per 100,000 population (a 5% reduction from 2013 levels).
• The decline is largely driven by the retirement of older physicians.

Nurse Practitioners and Physician Assistants

• The number of nurse practitioners (NPs) and physician assistants (PAs) is projected to increase significantly.
• NPs and PAs are expected to grow by 5.38 to 7.79 per 100,000 population by 2025.
• These increases are sufficient to support new practice models like medical homes and NMHCs.

Policy Option Effects

Policy Option	Scenario Detail	Predicted Effect
Open the Elson S. Floyd College of Medicine at WSU	60 students enroll in 2017 and 2018; 80 students enroll per year thereafter	Increase of 0.39 primary care physicians per 100,000 population
Increase the number of primary care residency positions	All existing primary care residencies outside Seattle expand by 100% in 2017	Increase of 2.00 primary care physicians per 100,000 population
Increase the availability of educational loan-repayment incentives	30 new full-time NHSC positions open in rural Washington in 2017	Increase of 1.03 primary care physicians per 100,000 population
Improve the quality of high school education in rural Washington	Proficiency rates on standardized tests increase by 0.2 standard deviations	Increase of 0.80 primary care physicians per 100,000 population
Preserve rural hospitals	One average-sized rural hospital is closed	Decrease of 0.87 primary care physicians per 100,000 population (four years after closure)
Increase Medicaid fee-for-service payment rates	25% increase in payment rates starting in 2017	Increase of 1.06 physician-equivalents per 100,000 population
Increase the adoption of medical home practice models	50% of existing rural primary care physicians adopt medical home models	Increase of 3.30 physician-equivalents per 100,000 population
Increase the adoption of NMHCs	1% of existing rural primary care physicians join NMHCs	Increase of 3.84 physician-equivalents per 100,000 population

Key Insights

• Opening a new medical school (Elson S. Floyd College of Medicine) is projected to offset 11–15% of the decline in primary care physician supply.
• Expanding residency programs can have a larger effect, with a 100% expansion offsetting 55% of the decline in rural areas.
• Loan-repayment incentives can increase the supply of primary care physicians, but their effect is less than residency expansion.
• Improving high school education in rural areas is seen as a long-term strategy, with an estimated increase of 0.80 physicians per 100,000 population.
• Preserving rural hospitals is critical, as their closure is associated with a 0.87 decrease in primary care physician supply.
• Increasing Medicaid payment rates by 25% is projected to increase productivity by 1.06 physician-equivalents per 100,000 population.
• Adopting medical home and NMHC models can significantly counterbalance the decline in physician supply. Medical home adoption (50%) is expected to increase productivity by 3.30, while NMHC adoption (1%) could increase it by 3.84, potentially offsetting the projected decline completely.

Conclusion

While none of the policy options alone are sufficient to fully offset the projected decline in primary care physician supply, combining strategies such as expanding residency programs, increasing Medicaid payments, and adopting new practice models can help maintain the availability of primary care services in rural Washington through 2025. The report emphasizes the importance of reallocating services to NPs and PAs, as their numbers are expected to grow enough to support these models. Additionally, improving rural education and preserving rural hospitals are highlighted as essential components of a comprehensive strategy to address primary care shortages.