California’s 1115 Waiver Renewal: Evidence of Effectiveness Sunita Mutha, MD, Joanne Spetz, PhD, Janet Coffman, PhD, and Margaret Fix, MPH Center for the Health Professions at UCSF December 11, 2014

 Recruitment and retention strategies  Telehealth  Scope of practice Outline

Recruitment and Retention Strategies

 Three major categories:  Applicant pool  Health professions education  Practice environment Recruitment and Retention Strategies _ K Grumbach et al. Strategies for Increasing Physician Supply in Medically Underserved Communities in California. Berkeley: California Program on Access to Care, California Policy Research Center, 1999

 The following types of recruitment and retention strategies increase the numbers of persons from underrepresented racial/ethnic groups who enter medical school:  Premedical enrichment and support programs (e.g., Health Careers Opportunity Program, Summer Medical and Dental Education Program)  Post-baccalaureate programs Applicant Pool Strategies Sources: K Grumbach and E Chen. Effectiveness of UC Postbaccaulareate Premedical Programs in Increasing Medical School Matriculation for Minority and Disadvantaged Students. JAMA 2006;296: K Grumbach et al. Strategies for Improving the Diversity of the Health Professions Workforce. The California Endowment, 2003.

 Physicians from underrepresented racial/ethnic groups who participate in University of California post- baccalaureate programs are more likely to practice in communities with high rates of poverty, and high concentrations of African-Americans or Latinos. Applicant Pool Strategies (cont.) Source: K Lupton et al. Specialty Choice and Practice Location of Physician Alumni of University of California Premedical Postbaccalaureate Programs. Acad Med, 2012:87:

 Graduates of medical school programs aimed at preparing physicians for practice in underserved areas are more likely to practice in such areas.  Examples:  Urban: UCLA/Drew Medical Education Program  Rural: Jefferson Physician Shortage Area Program Physician Education Strategies Sources: M Ko, et al. The Role of Medical Education in Reducing Health Care Disparities. JGIM, 2007; HK Rabinowitz, et al. A Program to Increase the Supply and Retention of Rural Primary Care Physicians. JAMA, 1999;281(3):

 Physicians who receive scholarships, loan repayments, and other financial support from state programs:  Practice in needier areas  Care for more Medicaid and uninsured patients  Remained longer in their practices Practice Environment Strategies Sources: DE Pathman et al. Outcomes of States’ Scholarship, Loan Repayment, and Related Programs for Physicians. Medical Care, 2004;42:

 Rates for completing service and retention are highest for loan repayment and direct incentives.  Loan repayment and direct incentives also have a more immediate impact on provider supply than scholarships Practice Environment Strategies* Sources: DE Pathman et al. Outcomes of States’ Scholarship, Loan Repayment, and Related Programs for Physicians. Medical Care, 2004;42: *Also applies to nurses

T Telehealth

 Telehealth technology can be used to facilitate interaction between health professionals and  Patients  Other health professionals Telehealth

 Two major types of telehealth technologies for interacting with patients  Live videoconferencing  Store-and-forward  Studied in multiple specialties including  Cardiology  Dermatology  Neurology  Ophthalmology  Psychiatry Telehealth - Patients Source: California Health Benefits Review Program. Analysis of AB 1771: Telephonic and Electronic Patient Management, 2014.

 Taken collectively, findings from studies of live videoconferencing and store-and-forward suggest that, for the diseases and conditions studied, the preponderance of evidence from controlled studies suggests that medical care provided by live videoconferencing and store- and-forward is at least as effective as medical care provided in person. Telehealth – Patients (cont.) Source: California Health Benefits Review Program. Analysis of AB 1771: Telephonic and Electronic Patient Management, 2014.

 Two major types of telehealth technologies for interacting with other health professionals  Synchronous (e.g., live videoconferencing)  Asynchronous (e.g., e-Consult) Telehealth – Other Health Professionals

 The Extension for Community Healthcare Outcomes (ECHO) model uses live videoconferencing to train primary care physicians in rural areas to manage patients with complex health problems, such as Hepatitis C virus (HCV)  No statistically significant difference in sustained viral response between HCV patients treated under the ECHO model and in an academic health center’s HCV clinic Telehealth – Other Health Professionals (cont.) Source: Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. NEJM. 2011;364:

 Some multi-specialty groups have implemented an electronic referral system that facilitates communication between primary care and specialty clinicians to improve the referral process.  A study at San Francisco General Hospital found that electronic referral was associated with reductions in  Inappropriate referrals  Avoidable visits to specialists Telehealth – Other Health Professionals (cont.) _ Source: Kim-Hwang JE, Chen AH, Bell DS, Guzman D, Yee HF Jr., Kushel MB. Evaluating electronic referrals for specialty care at a public hospital. Journal of General Internal Medicine. 2010;25:

S Scope of Practice

 NPs cannot prescribe methadone  NPs cannot order durable medical equipment  No studies to support that NPs cannot do these things safely Federal barriers to NP practice

 NPs don’t have access to paid residencies to advance knowledge after graduation  Many hospitals do not give NPs admitting privileges  Some practices/clinics have greater oversight requirements than mandated by law Organizational barriers to NP practice in CA

 Numerous studies of NPs in primary care demonstrate safety, quality, and high patient satisfaction.  Greater access to and autonomy of NPs is associated with better access to care and lower costs. Evidence of the safety and value of NP practice Sources: Mundinger M, et al. Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians, A Randomized Trial. JAMA, Newhouse R, et al. Advanced Practice Nurse Outcomes : A Systematic Review. Nursing Economics, Traczynski J, Udalova V. Nurse Practitioner Independence, Health Care Utilization, and Health Outcomes. Working paper, Spetz J, et al. Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics. Health Affairs, Stange, K. How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants. Journal of Health Economics, 2013.