Population Health Management and Physician Staffing

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1 Ppulatin Health Management and Physician Staffing A resurce prvided by Merritt Hawkins, the natin s leading physician search and cnsulting firm and a cmpany f AMN Healthcare (NYSE: AHS), the largest healthcare wrkfrce slutins cmpany in the United States Merritt Hawkins 5001 Statesman Drive Irving, Texas 75063

2 POPULATION HEALTH MANAGEMENT AND PHYSICIAN STAFFING A resurce prvided by Merritt Hawkins, the natin s leading physician search and cnsulting firm and a cmpany f AMN Healthcare Abut Merritt Hawkins Established in 1987, Merritt Hawkins is the leading physician search and cnsulting firm in the United States and is a cmpany f AMN Healthcare (NYSE: AHS), the largest healthcare wrkfrce slutins rganizatin in the natin. Merritt Hawkins prduces a series f surveys, white papers, bks, and speaking presentatins internally and als prduces research and thught leadership fr third parties. Organizatins fr which Merritt Hawkins has cmpleted research and analysis prjects include The Physicians Fundatin, the Indian Health Service, Trinity University, the American Academy f Physician Assistants and the Nrth Texas Reginal Extensin Center. This is ne in a series f Merritt Hawkins white papers examining a variety f tpics directly r indirectly affecting the recruitment and retentin f physicians and advanced practice prfessinals, including physician (PAs) and nurse practitiner (NPs). Additinal Merritt Hawkins white papers include: Psychiatry: The Silent Shrtage Physician Supply Cmparisns: Physicians by Select Specialties Practicing in Each State and Licensed in Each State but Practicing Elsewhere The Aging Physician Wrkfrce: A Demgraphic Dilemma Nurse Practitiners and Physician Assistants: Supply, Distributin, and Scpe f Practice Cnsideratins The Physician Shrtage: Data Pints and State Rankings Physician Supply Cnsideratins: The Emerging Shrtage f Medical Specialists RVU FAQ: Understanding RVU Cmpensatin in Physician Emplyment Agreements The Ecnmic Impact f Physicians Ten Keys t Physician Retentin Trends in Incentive-Based Physician Cmpensatin Overview The advent f the Affrdable Care Act (ACA) has been ne f a number f influencers that are shifting the fcus and delivery f healthcare, placing a premium n quality f care and the effective management f patient health. While a fee-fr-service apprach that rewards prviders fr vlume f service delivered has been the prevailing mdel, healthcare managers and clinicians are mving tward a different apprach. The cncept f ppulatin health management- a system in which a team-based grup f prviders wrks t imprve healthcare cverage fr large patient grups- is gaining mmentum. In this white paper, Merritt Hawkins examines the develpment f ppulatin health management, cmpnent elements, and hw healthcare rganizatins are implementing and staffing this emerging delivery mdel.

3 What is Ppulatin Health Management? Ppulatin health management is generally understd as a healthcare delivery mdel in which an integrated healthcare rganizatin prvides care fr defined ppulatin grups, managing care and assuming financial risk. In assuming risk, the integrated healthcare rganizatin accepts fixed r bundled payments fr prviding care t ppulatin grups frm third party payers such as Medicare r private insurance grups. Payments (r financial penalties) als may be tied t quality utcmes r guidelines. Thugh there may nt be an abslute definitin f the term, ppulatin health management generally is characterized by the fllwing three elements: 1. Infrmatin based clinical decisin making Rbust patient data supprts cmprehensive, evidence-based care. All clinicians/facilities share an integrated data netwrk. A psitin leader, typically a physician, merges data analytics with clinical care decisin making. 2. Primary care-led clinical wrkfrce Primary care physicians are the pint guards, managing the team and distributing care as needed. Care team extends reach int the cmmunity t manage/direct utcmes. 3. Patient Engagement and Cmmunity Integratin Services are mapped t ppulatin need. Nn-clinical barriers t gd utcmes addressed. Patient values integrated int the care plan. Cmmunity stakehlders cnnect patients t resurces. Surce: Three Key Elements fr Successful Ppulatin Health Management. The Advisry Bard Cmpany In the future, implementatin f this mdel will be driven thrugh inter-prfessinal educatin, in which cllabrative practice techniques will replace the current apprach that features clinicians training in sils and subsequently taking the sil apprach int the wrkplace. Tday the mdel is being implemented thrugh a grwing number f accuntable care rganizatins (ACOs) large medical grups, and hspital systems that have achieved staffing, management, and infrmatin technlgy integratin. Central t the delivery f ppulatin health management is the primary care-led team, which is n the frnt lines f patient care. The cmpsitin f this team is as fllws:

4 Chief Integratin Officer Chief Ppulatin Health Officer Chief Transfrmatin Officer Family Medicine Physician General Internist Nurse Care Manager Physician Assistant Nurse Practitiner Cmmunity Resurces Specialist Scial Wrker Care Crdinatr Grand Aide Surce: Three Key Elements fr Successful Ppulatin Health Management. The Advisry Bard Cmpany At the tp f the pyramid is the executive leader respnsible fr designing and implementing the ppulatin health management mdel and staffing, managing and creating incentive prgrams fr the primary careled team. This executive may hld ne f several cmparatively new titles, including Chief Ppulatin Health Officer, Chief Integratin Officer, r Chief Transfrmatin Officer. He r she is the change agent respnsible fr directing the shift away frm a vlume based system t ne based n value/quality. Often, this leader is a physician r ther clinician with the management acumen t represent administratin and the medical knwledge needed t achieve the trust and buy-in f care givers. Within the framewrk set by the executive leader, primary care physicians such as family physicians and general internists are the (pick ne) pint guards, quarterbacks, r CEOs f the delivery team. Thrugh the patient management and care crdinatin they prvide, quality gals are achieved within an envirnment f defined (capitated) financial resurces. Primary care physicians then are rewarded fr the savings they realize within a glbal payment structure, the quality standards they achieve and fr their managerial rle. Primary care physicians in this mdel practice t the tp f their training, ften managing the needs f patients with multiple chrnic cnditins while wrking with nurse case managers wh help ensure that wrk is allcated t the apprpriate clinician (including PAs and NPs) and that patient care is managed, even utside f the ffice. Patient utreach and care management is prvided by scial wrkers, cmmunity resurce specialists, care crdinatrs and grand aides, wh wrk directly with patients (ften in their hmes) t ensure treatment plans are fllwed and utcmes mre clsely cntrlled. These prfessinals als may wrk t ensure the imprvement f scial cnditins that can affect the health f the cvered ppulatin grup, ften thrugh patient educatin Medical specialists are integrated int the team when apprpriate by the primary care physician. Certain medical specialties are particularly central t ppulatin health management, due primarily t the rle these physicians play in chrnic disease management. These specialties include: Psychiatry: One in every five adults in America experiences sme frm f a mental illness, with the average delay between nset f mental health symptms and interventin being 8-10 years. These cnditins generally require management ver time and crdinatin with ther types f physicians.

5 Obstetrics/Gyneclgy (OBGYN): Imprtant fr wmen s health management, including preventive measures such as wellness visits and cancer screenings, OB/GYNs are seen as central t ppulatin health management by prmting psitive behavirs that can affect the next generatin f patients. Cardilgy: Vital fr evaluatin f heart cnditins- including heart disease (the number ne cause f death in the United States), hypertensin, and ther chrnic issues. Heart-related cnditins typically ccur in lder patients that have multiple chrnic cnditins, and thus it is essential that prviders are n the same page in terms f medicatin management, diet and fitness regimen, and patient understanding and educatin f cnditin(s). Pulmnlgy: Anther key prvider in management f chrnic cnditins- particularly COPD, the third leading cause f death in the United States and the nly leading cause f death which has increased ver the last 40 years. Patients under the care f a pulmnlgist typically have many scial determinants that lead t cnditins, including lng-term tbacc use and smking, lder age with lw activity level/fitness, and high unemplyment rate with lw incme level. Thus, patient educatin, understanding f care, and cnsistent management f cnditin is imprtant t prevent life-threatening symptms and ER admissins. Gastrenterlgy Cnsideratins fr disease preventin are very imprtant in the cntext f ppulatin health; gastrenterlgists prvide disease screenings thrugh clnscpies, an essential step t mnitr fr cln cancer. Hspitalist: As a part f imprving quality f care, hspitals and ther healthcare systems are cntinually evaluating hw t decrease the likelihd f readmissin fr patients- either fr the same ailment/cnditin that caused admissin, r a prblem that develps as a result f the initial stay. Hspitalists may enhance quality, reduce errrs and serve as key care crdinatrs during the stay. Neurlgist The management f chrnic pain, strke, Alzheimer s, Parkinsn s, sleep apnea and related neurlgical disrders will becme a greater pririty as the ppulatin ages, increasing demand fr neurlgists. All clinicians and facilities share an integrated data netwrk and may use big data t implement evidencebased treatment prtcls and crdinate care. The aspiratin is that quality will be enhanced, that thrugh preventin and apprpriate use f resurces csts will be reduced, and that rganizatins implementing ppulatin health management will share in the savings they realize.

6 Frequent Flyers and Readmissins Implementing ppulatin health management includes understanding patient ppulatin characteristics -- primarily thrugh identifying and managing patient grups that utilize health services the mst and are at risk fr health cmplicatins. These patient grups are ften referred t as frequent flyers r htsptters - a small subset f the patient ppulatin that utilizes a disprprtinate amunt f health services, and culd be mre efficiently cared fr and managed thrugh an integrated and crdinated health system. As prfiled in Health Leaders in May 2015, Intermuntain Healthcare ut f Salt Lake City, Utah fund between , that this ht-sptting prtin f their patient ppulatin (5% f the ttal) accunted fr 51% f csts. Many f these patients shared similar prfiles- multiple chrnic cnditins that required frequent physician specialist visits- withut crdinatin thrugh a primary care physician. (Surce: Health Leaders, Ppulatin Health Ht-Sptting, May 2015). Case studies such as these identify a persistent issue in current health care that ppulatin management attempts t address. Crdinating medical infrmatin, patient prfiles and visits amng primary care physicians and specialists reduces the need fr extraneus health encunters- while reducing csts fr the patient and allwing physicians increased capacity fr care. This increased crdinatin als reduces the likelihd that patients with significant risk factrs will develp emergent r life-threatening cmplicatins, saving patient lives and imprving quality metrics in the prcess. Shuld patients need in-patient services, the ppulatin health management mdel seeks t reduce readmissins thrugh the care crdinatin and fllw-up measure referenced abve. Kaiser Health News reprted in August, 2015 that hspital readmissins will cst hspitals $420 millin due t federal readmissins penalties and that 2,592 hspitals will be subject t these penalties. Thugh readmissin rates have drpped since the readmissin penalties went int effect, abut ne f every five Medicare patients sent t the hspital ends up returning within a mnth. Reducing r eliminating such penalties is ne gal f ppulatin health management. Ppulatin health management is seen as a prmising delivery mdel because f the emphasis it places n quality patient utcmes- and cntinually imprving thse utcmes. Rather than treating symptms thrugh vlume f services it seeks t address causes thrugh care crdinatin and management, with quality/value as part f prvider rewards. Accuntable Care Organizatins The Affrdable Care Act prmtes the establishment f accuntable care rganizatins (ACOs) which have the integrated structure t implement ppulatin health management. The ACO/ppulatin health management mdel falls in line with the Institute fr Healthcare Imprvement s Triple Aim. The gals f the Triple Aim include: 1) Imprving patient experience f care; 2) Imprving health f ppulatins; and 3) Reducing per capita cst f care. Surce: Institute fr Healthcare Imprvement; An ACO is a grup f prviders wh are willing and able t take respnsibility fr imprving the verall health status, care efficiency, and health care experience fr a defined ppulatin - a vital resurce fr the implementatin f imprved crdinated care (see Driving Ppulatin Health Thrugh Accuntable Care Organizatins, Health Affairs). This grup f prviders jintly shares respnsibility fr the crdinated care f patients all while attempting t keep csts within a defined budget.

7 As f April 2014, 428 prvider grups were perating as ACOs, servicing 14% f the United States ppulatin and fur millin Medicare beneficiaries (see Kaiser Health News, FAQ n ACOs, April 2014). Glbal management cnsulting firm Oliver Wyman prjects an even greater number f healthcare rganizatins perating as ACOs, with 522 ACOs in the United States, including millin patients serviced under these ACOs (see ACO Update: Accuntable Care at a Tipping Pint, Oliver Wyman, April 2014; Cpyright 2013, Oliver Wyman). At present, ACOs, r systems acting as ACOs, are the primary implementers f ppulatin health management. ACO Prgrams ACOs can fall int tw distinct categries, as either participating in Centers fr Medicaid and Medicare Services (CMS) prgrams r nn-cms prgrams. CMS ACOs service bth Medicare and nn-medicare beneficiaries (althugh primarily Medicare beneficiaries), and receive financial incentives frm CMS tied t imprved quality-cntrl and crdinatin f care. Mdels under CMS ACOs include: Medicare Shared Savings Prgram: Financial incentives prvided t participating ACOs based n evaluatin f quality-care metrics fr Medicare patients (includes Advanced Payment ACO Mdel, where participating rural-based physician prviders are prvided upfrnt payments t invest in imprved care) Pineer ACO Mdel: designed fr healthcare systems that already utilize effective crdinated care, with emphasis t shift t ppulatin management care. Accrding t CMS, there are currently 405 ACOs participating in the Medicare Shared Savings Prgram and 19 ACOs participating in the Pineer ACO Mdel. Nn-CMS ACOs are thse that participate in a shared-savings r risk agreement with an independent cmmercial payer nt tied t the CMS. Oliver Wyman estimates there are 154 nn-cms ACOs as f April Surce: Oliver Wyman, ACO Update: Accuntable Care at a Tipping Pint ; Cpyright 2013, Oliver Wyman

8 Surce: Centers fr Medicare and Medicaid Services (CMS) Medicare Shared Savings and Financial Incentives The majrity f healthcare rganizatins that are ACOs participate in the Medicare Shared Savings Prgram, as indicated by the 405 participating rganizatins referenced abve. CMS evaluates the perfrmance f participating ACOs each year based n 33 quality perfrmance measures, with adequate perfrmance in these areas resulting in the rewarding f financial incentives. The fur key dmains emphasized include: Patient/caregiver experience Care crdinatin/patient safety At-risk ppulatin, including patients with: Diabetes Hypertensin Ischemic Vascular Disease Heart Failure Crnary Artery Disease Preventive Care Surce: Centers fr Medicare and Medicaid Services (CMS); Payment/sharedsavingsprgram/Dwnlads/ACO-NarrativeMeasures-Specs.pdf In rder t be accepted as an ACO under the Medicare Shared Savings Prgram, the rganizatin in questin must agree t accept at least 5,000 Medicare fee-fr-service beneficiaries. The applicatin prcess als includes detailing hw the ACO plans t integrate imprved quality f care and lwer csts

9 fr beneficiaries. The term fr participatin in the Shared Savings Prgram with CMS is a minimum f three years. Primary care physicians under an ACO are nly cnsidered t be thse in internal Medicine (IM), general practice (GP), family practice (FP) r geriatric medicine. Althugh patients under an ACO may receive treatment frm advanced practitiners including NPs and PAs, a physician in the apprpriate specialty must be cnsidered the patient s primary prvider in rder fr the patient t fall under the 5,000 beneficiary requirement fr ACOs. ACO Case Studies Althugh the integratin f ACOs int the health system is still emerging, there have been case studies f encuraging returns and imprvement in quality f care. Recently prfiled in the March 2015 issue f Health Leaders, University Hspitals in Cleveland established the University Hspitals Accuntable Care Organizatin (UHACO) in 2010 within their 15 hspital system. UHACO reprted multiple integrated changes in their EMR and billing system ver the past five years, with data cllected in their system used t supplement inpatient care. This quantifiable data led t real changes in the way care was prvided in their system; fr example, a deficiency f mammgram and clrectal cancer screenings nticed within their emplyee EMR led t an increase f 11% in mammgrams and 8% in clrectal screenings fr emplyee medical plans. Surce: Health Leaders, Ppulatin Health and the Revenue Cycle, March 2015 Other healthcare systems are fcusing n areas f demand and grwth within the ppulatins they are servicing. Virtua Health System in New Jersey, featured in anther Health Leaders prfile, has established VirtuaCare and ther ACOs under their system, servicing nearly 50,000 patients. As a part f their quality care evaluatin, they plan t increase utpatient capacity t fit a grwing need- including dubling their urgent care centers. This expansin marks an emerging trend in accessibility f care- with urgent care prviders supplementing care fr PCPs and emergency department physicians. Surce: Health Leaders, These 4 Strategies Make Ppulatin Health Thrive, Health Leaders, June 2015 Despite these gains, the smth integratin f ppulatin health metrics still has sme nted areas where imprvement is indicated. In April f 2015, CMS released their first five-star rating system fr patient experience in hspitals, with the returns revealing sme shrtcmings in patient satisfactin. Cnducted by the Hspital Cnsumer Assessment f Healthcare Prviders and Systems (HCAHPS) fr 3,553 hspitals, the majrity f hspitals received either 3 star (40%) r 4 star (34%) ratings as given by patients. A breakdwn belw is prvided:

10 HCAHPS Hspital Experience Rating 7% 3% 16% 34% 40% 1 Star 2 Star 3 Star 4 Star 5 Star Surce: Health Leaders Media, Medicare Issues its First Star Ratings fr Patient Experience ; HCAHPS Althugh patient-directed rating systems d nt paint the full picture n quality f care and experience healthcare systems prvide, they are an imprtant indicatr f the satisfactin level f thse receiving care. As healthcare systems cntinue t evaluate the best methds fr care imprvement, it will be imprtant t cnsider the pinin f the nes receiving care themselves - patients. Staffing Cnsideratins With the PCP serving as the quarterback f the care crdinatin team, it is natural t evaluate supply f PCPs within the United States as a pririty fr ppulatin health management. Using the Medicare Shared Savings Prgram s definitin f a primary care physician- general practice, family practice, internal medicine, r geriatric medicine- there are currently 204,095 PCPs practicing actively in the United States. The tp 5 states in terms f PCP supply- Califrnia, New Yrk, Texas, Flrida and Illinis- cmprise 35.9% f the primary care physician wrkfrce as defined by the Shared Savings Prgram. When evaluated n a per capita basis, hwever, the states with the mst PCPs are as fllws: State/Regin Ttal PCPs PCPs per 100,000 Washingtn, D.C Massachusetts 6, Maine 1, Rhde Island Vermnt Maryland 4, Minnesta 4, Oregn 3, New Yrk 14, New Hampshire Cnnecticut 2, Nrth Dakta

11 Hawaii 1, Illinis 9, Suth Dakta Pennsylvania 9, Wiscnsin 3, Alaska Washingtn 4, New Jersey 6, Nebraska 1, West Virginia 1, Virginia 5, Clrad 3, Iwa 2, Michigan 6, Ohi 7, Kansas 1, Mntana Califrnia 24, New Mexic 1, Tennessee 3, Nrth Carlina 6, Wyming Delaware Suth Carlina 2, Flrida 11, Indiana 3, Missuri 3, Arkansas 1, Luisiana 2, Gergia 5, Alabama 2, Idah Arizna 3, Kentucky 2, Nevada 1, Texas 13, Oklahma 1, Utah 1, Mississippi 1, United States 204, Surce: AMA Master File/MMS List Belw are suggested physician-t-ppulatin ratis as determined by Richard A. Cper, M.D., a natinally knwn physician supply and utilizatin expert at the University f Pennsylvania/Whartn Schl and Directr f the Center fr the Future f the Healthcare Wrkfrce at the New Yrk Institute f Technlgy. These are demand-based ratis that suggest the number f physicians that can be ecnmically supprted by a given ppulatin. Calculated in 2013, they are the mst recent such ratis

12 f which Merritt Hawkins is aware; they are als the mst real wrld ratis applicable, as they indicate nt hw many physicians a ppulatin may theretically need, but hw many it can sustain given ecnmic and demgraphic cnsideratins. Ppulatin Needed t Supprt One Physician by Specialty Family Medicine 3,100 Internal Medicine 3,378 Cardilgy 14,084 Obstetrics/Gyneclgy 7,692 Psychiatry 6,802 per 5,000 ppulatin Family Medicine 1.61 Internal Medicine 1.48 Cardilgy 0.36 Obstetrics/Gyneclgy 0.65 Psychiatry 0.74 per 50,000 ppulatin Family Medicine 16.1 Internal Medicine 14.8 Cardilgy 3.6 Obstetrics/Gyneclgy 6.5 Psychiatry 7.4 per 100,000 ppulatin Family Medicine 32.2 Internal Medicine 29.6 Cardilgy 7.1 Obstetrics/Gyneclgy 13.0 Psychiatry 14.7 Surce: Richard A. Cper, M.D./University f Pennsylvania/Whartn Schl These numbers are natinal ratis and may nt reflect the needs f specific ppulatin grups which can vary widely by age and verall health. Hwever, they d ffer sme guidelines fr the number f physicians in varius specialties needed t implement the ppulatin health management mdel. With an aging United States ppulatin, it is likely that the demand fr PCPs and ther specialty services may be even greater than indicated by these numbers. Current ppulatin cmpsitin reveals that 14.1% f the U.S. ppulatin is 65 years f age r lder- the prtin f the ppulatin that requires the mst healthcare cverage. This includes nearly 50 millin individuals that access Medicare fr health insurance cverage (fr mre infrmatin n this tpic, see the white paper The Aging Physician Wrkfrce: A Demgraphic Dilemma, Merritt Hawkins, 2015). Individuals aged 65 and lder drive the greatest demand fr healthcare services. Over 96% have a regular healthcare prvider; nearly 94% f individuals in this age grup have seen a prvider in the last year; and 37.4% f in-patient prcedures and 47.1% f diagnstic testing/treatments were undergne by individuals aged 65 and lder, accrding t 2010 data frm the CDC.

13 This demand is heightened by a stark reality- this prtin f the ppulatin will cntinue t grw, while a retiring physician ppulatin will exit the wrkfrce and jin their peers in demand fr healthcare services. Early Census Bureau prjectins estimate the U.S. ppulatin age 65 and lder t be 56,441,000 by 2020, nearly 25.5% grwth ver that time perid. With this in mind, healthcare leaders will have t evaluate prvider and practitiner supply based n the lming demand, nt necessarily just by the current landscape. Overall, the natinal average fr PCPs per 100,000 residents is 64, with ppulus states including Texas, Flrida, and Califrnia falling belw this number. Fr ther specialties particularly imprtant t ppulatin health management, per capita supply numbers fr each specialty are included belw, including the tp 10 and bttm 10 states/regins in physicians r advanced practitiners per capita: State/Regin Cardilgists per 100,000 State/Regin Pulmnlgists per 100,000 Washingtn, D.C Washingtn, D.C Massachusetts 12.3 Massachusetts 7.3 New Yrk 10.8 Cnnecticut 7.0 Rhde Island 10.6 Rhde Island 6.1 New Jersey 10.6 Maryland 6.0 Cnnecticut 10.5 New Yrk 5.8 Pennsylvania 9.9 New Jersey 5.4 Maryland 9.2 Vermnt 5.3 Flrida 8.2 Pennsylvania 5.2 Luisiana 8.0 Maine New Mexic 5.0 Mississippi 3.0 Washingtn 4.9 Texas 2.9 Mntana 4.8 Nrth Dakta 2.8

14 Hawaii 4.6 Iwa 2.8 Clrad 4.4 Oklahma 2.7 Utah 4.3 Alaska 2.6 Alaska 3.7 Idah 2.6 Idah 3.1 Arkansas 2.3 Wyming 2.9 Nevada 2.0 Natinal Average 7.1 Wyming 1.7 Natinal Average 4.1 State/Regin Gastrenterlgists Nephrlgists per 100,000 State/Regin OBGYNs per 100,000 Washingtn, D.C Washingtn, D.C Massachusetts 12.5 Cnnecticut 19.2 Cnnecticut 11.6 Rhde Island 19.1 New Yrk 11.2 Maryland 18.3 New Jersey 10.7 Vermnt 17.9 Maryland 10.2 New Yrk 16.4 Rhde Island 10.2 New Jersey 16.3 Pennsylvania 9.7 Massachusetts 15.8 Flrida 8.0 Hawaii 15.2 Minnesta 7.9 Oregn Nebraska 5.5 Kentucky 10.3 New Mexic 5.5 West Virginia 10.2 Arkansas 5.3 Idah 10.0 Nevada 5.2 Nrth Dakta 10.0 Oklahma 5.0 Nevada 9.9 Utah 4.5 Suth Dakta 9.5 Iwa 4.3 Arkansas 9.4 Idah 4.2 Delaware 9.3 Alaska 4.1 Oklahma 9.1 Wyming 3.6 Iwa 8.7 Mntana 3.5 Natinal Average 13.0 Natinal Average 7.5 State/Regin Hspitalists per 100,000 State/Regin Psychiatrists per 100,000 Maine 7.8 Washingtn, D.C Cnnecticut 5.1 Massachusetts 17.9 New Hampshire 5.1 Rhde Island 17.2 Washingtn, D.C. 4.2 Vermnt 16.3 Massachusetts 4.2 Cnnecticut 15.8

15 Hawaii 4.2 New Yrk 15.4 Nrth Carlina 3.3 Maryland 13.7 Delaware 3.2 Maine 11.5 Maryland 3.1 New Hampshire 10.8 Nevada 3.0 New Jersey West Virginia 1.7 Utah 6.3 Luisiana 1.6 Alabama 6.3 Iwa 1.6 Nebraska 6.2 New Jersey 1.6 Wyming 5.8 Idah 1.5 Texas 5.7 Oklahma 1.4 Iwa 5.6 Alaska 1.2 Mississippi 5.3 Nrth Dakta 1.2 Indiana 5.2 Arkansas 1.2 Nevada 5.1 Wyming 1.0 Idah 5.1 Natinal Average 2.4 Natinal Average 13.0 State/Regin NPs per 100,000 State/Regin PAs per 100,000 Massachusetts 107 Alaska 63 Tennessee 102 Suth Dakta 60 Cnnecticut 99 Maine 57 New Hampshire 96 New Yrk 55 Delaware 96 Pennsylvania 52 Maine 92 Nebraska 52 Alaska 86 West Virginia 51 Vermnt 84 Nrth Carlina 50 Mississippi 82 Mntana 50 Kentucky 82 Cnnecticut Wyming 53 Tennessee 24 Suth Carlina 53 Nevada 24 Idah 52 Illinis 21 Utah 51 Luisiana 19 Michigan 47 Indiana 16 Califrnia 44 Hawaii 16 Texas 41 Missuri 15 Oklahma 37 Alabama 15 Nevada 34 Arkansas 10 Hawaii 29 Mississippi 5 Natinal Average 60 Natinal Average 33

16 Critical Access Areas Under ppulatin health management, primary care physicians serve as directr f patient care and needs, facilitating further treatment fr cncentrated and chrnic cnditins as needed t specialists. Advanced practitiners such as PAs and NPs play a supplementary rle fr prviding care t patients, filling gaps in PCP care as needed. Based n per capita supply numbers f PCPs, PAs and NPs, we have identified several critical access areas under the scpe f ppulatin health management. These states/regins all have physician and advanced practitiner per capita supply numbers that fall belw the natinal average, ne ptential sign that a significant shift t ppulatin health management wuld prve difficult. These states/regins include: Alabama, Arkansas, Califrnia, Gergia, Indiana, Luisiana, Nevada, Suth Carlina, Texas, and Utah. As these states mve frward, and the demand fr ppulatin-based healthcare cverage grws, it will be essential fr these states t evaluate current supply f primary care physicians and advanced practitiners, evlving current plicies as needed.

17 Cnclusin As healthcare rganizatins cntinue t evaluate the best methds f care delivery, new mdels will be needed t ensure healthcare gals are achieved within an envirnment f fixed budgets. Ppulatin health management -- in which health utcmes f a ppulatin are mnitred and imprved thrugh risk management, care crdinatin, investment in educatin and patient utreach- may be a prmising mdel that currently is typically implemented by accuntable care rganizatins (ACOs). There are many challenges that need t be addressed by healthcare systems in implementing ppulatin health management. Chief amng these cncerns is creating the right mix f physicians, advanced practitiners and ther healthcare prfessinals needed t create primary-care led teams. A cmprehensive, strategic staffing strategy may include the apprpriate use f temprary (lcum tenens) healthcare prfessinals. Fr additinal infrmatin n ppulatin health management, cntact: Crprate Office: Eastern Reginal Office: Merritt Hawkins Merritt Hawkins 5001 Statesman Drive 7000 Central Pkwy NE Irving, Texas Suite Atlanta, Gergia Merritt Hawkins 5001 Statesman Drive Irving, Texas 75063

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