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Rural Health Information Hub
Rural Health Information Hub

Testing New Approaches

Why Rural-Specific Demonstration Projects Are Needed

The healthcare delivery system is undergoing dramatic change, with an emphasis on finding new approaches and organizational frameworks to:

  • improve health outcomes,
  • control costs,
  • improve population health, and
  • advance health equity

Financial incentives are changing from a focus on volume-based services to value-based services. There is a concurrent need to better measure and account for quality of care in all settings and improve transitions of care as patients move from one care setting to another.

Advances in technology and new approaches to organizing care delivery are occurring quickly, with examples like the patient-centered medical home, accountable care organizations, and patient-safety organizations.

Most early adopters of new care models have been large, urban-based integrated delivery systems. Less is known about how these changes and environmental factors will affect rural healthcare delivery systems. Because rural healthcare providers are often paid outside of the traditional prospective payment systems and fee schedules, there is less known about how new and emerging models might function in rural communities. As a result, policy makers and rural providers need to better understand the implications of new and emerging models for low-volume rural settings.

The Centers for Medicare & Medicaid Services (CMS) Innovation Center was established through the Affordable Care Act. The CMS Innovation Center tests new payment and service delivery models that may reduce cost, while also providing care of similar or higher quality. The 2021 CMS Innovation Center Strategy Refresh discusses the continued potential for CMS demonstrations to address the needs of rural providers and expand the reach of demonstration programs to Medicare and Medicaid beneficiaries in rural and underserved areas. CMS Innovation Center: 2022 Report to Congress presents summaries and updates to payment and service delivery models and initiatives tested or announced between October 2020 and September 2022.

The Rural Health Value program, with support from a Federal Office of Rural Health Policy (FORHP) cooperative agreement, examines the rural implications of demonstration projects and other changes to healthcare organization, finance, and delivery. The Rural Health Value website provides analyses of innovations undertaken in a rural setting, as well as resources for organizations interested in undertaking similar programs.

Rural-Specific Initiatives Being Tested by HRSA

  • Rural Maternity and Obstetrics Management Strategies (RMOMS) Program – ongoing
    Focuses on improving maternal healthcare in rural communities. Funded by the Health Resources and Services Administration's (HRSA) Federal Office of Rural Health Policy (FORHP) and Maternal and Child Health Bureau (MCHB), this four-year program allows awardees to test models of maternal healthcare to address unmet needs for populations that may experience poor health outcomes, health disparities, and other inequities. The first cohort (2019-2023) includes rural networks in Missouri, New Mexico, and Texas. Evaluation of the Rural Maternity and Obstetrics Management Strategies Program: First Annual Report provides an overview of the first cohort’s 2019-2020 planning year, their planned approaches to the program, and early lessons learned. The second cohort (2021-2025) includes rural networks in Minnesota, Missouri, and West Virginia.
  • Rural Residency Planning and Development Program Awards – ongoing
    An initiative from the Health Resources and Services Administration (HRSA) to expand the physician workforce in rural communities. Since 2019, HRSA has awarded three-year grants to develop rural residency programs in family medicine, internal medicine, and psychiatry. Grant recipients include rural hospitals, community health centers, Indian Health Service-operated health centers, Indian tribes and tribal organizations, and schools of medicine. In fiscal year 2022, HRSA awarded 13 additional grants to recipients in 10 states.

Rural-Specific Demonstrations Being Tested by CMS

  • Community Health Access and Rural Transformation (CHART) Model – Concluding Sept 2023
    A rural-focused initiative intended to address rural health disparities through healthcare delivery transformation and regulatory flexibilities. This model originally included two tracks for participation. In February 2022, however, CMS announced it removed the previously-publicized Accountable Care Organizations (ACO) Transformation Track from the CHART Model and would instead examine lessons learned from the previously completed CMS Innovation Center’s ACO Investment Model (AIM) to inform future ACO policies. The remaining track, the Community Transformation Track, is designed to fund rural communities to develop and implement a healthcare delivery redesign strategy. In September 2021, CMS announced cooperative agreements with the University of Alabama at Birmingham, State of South Dakota Department of Social Services, Texas Health and Human Services Commission, and Washington State Healthcare Authority to serve as lead organizations in their respective states under the Community Transformation Track. However, in March 2023, the CMS Innovation Center announced that “[b]ased on feedback received from Model stakeholders, as well as a lack of hospital participation, the CHART Model will end early on September 30, 2023. CMS believes that the lessons learned from the CHART Model will continue to aid in the development of a potential future rural healthcare model at the CMS Innovation Center.”
  • Frontier Community Health Integration Project (FCHIP) – extension period announced
    Developed and tested new models for the delivery of healthcare services in frontier areas through improving access to, and better integration of, the delivery of healthcare to Medicare beneficiaries. The Consolidated Appropriations Act, 2021, authorized a five-year extension period for participating Critical Access Hospitals beginning on July 1, 2021.
  • Pennsylvania Rural Health Model – ongoing
    Designed to improve the financial viability of rural Pennsylvania hospitals and reduce the growth of hospital expenditures across payers, including Medicare. Participating rural hospitals will be paid monthly based on fixed all-payer global budgets and redesign their healthcare delivery system to improve quality and access in rural Pennsylvania communities. Jointly administered by CMS and the Pennsylvania Department of Health, the model is open to Critical Access Hospitals and acute care hospitals in rural Pennsylvania. The Pennsylvania Rural Health Model (PARHM): Second Annual Evaluation Report evaluates the second performance year of the model.

    A similar model, the Maryland Total Cost of Care (TCOC) Model, is underway for the entire state of Maryland, including rural areas, and sets a per capita limit on Medicare total cost of care in Maryland. Evaluation of the Maryland Total Cost of Care Model: Quantitative-Only Report for the Model's First Three Years (2019 to 2021) estimates the impact of the first three years of the model.
  • Rural Community Hospital Demonstration – ongoing
    Implements cost-based reimbursement in participating small rural hospitals that are not eligible for Critical Access Hospital designation. Designed to assess the impact of cost-based reimbursement on the financial viability of small rural hospitals, and test for benefits to the community. Evaluation of the Rural Community Hospital Demonstration: Interim Report Two (Covering 2016-2018), issued in December 2022, describes the 29 hospitals participating in the model as of fiscal year 2018 and the impact of the program on hospital finances.

Rural-Relevant Demonstrations Involving Accountable Care Organizations (ACOs)

Additional Rural-Relevant Demonstrations Being Tested by CMS

  • Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model – ongoing
    A redesign of the Global and Professional Direct Contracting (GPDC) Model intended to encourage healthcare coordination to improve care for people with Medicare, especially those from underserved communities. CMS will use the ACO REACH model to test an ACO model that can inform the Medicare Shared Savings Program and future models. Changes to the GPDC Model incorporated into the ACO REACH Model include advancing health equity; promoting leadership and governance; and increasing participant vetting, monitoring, and transparency.
  • AHEAD Model – announced
    A voluntary state total cost of care (TCOC) model, the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model will test state accountability for controlling overall growth in health expenditures while increasing investment in primary care and improving population health outcomes within the state or a region within the state. The AHEAD Model aims to improve the total health of state populations and lower healthcare costs through strengthening primary care, improving care coordination, and increasing screening and referrals to community resources to address social drivers of health. AHEAD is built on lessons learned from the Maryland Total Cost of Care Model, the Vermont All-Payer ACO Model, and the Pennsylvania Rural Health Model. CMS plans to award cooperative agreements to up to eight states across two application periods. States will be able to apply to participate in one of three cohorts, depending on their readiness to implement the model. The AHEAD Model is scheduled to operate for a total of 11 years, from 2024 through 2034.
  • Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model – ongoing
    Participating providers receive a single bundled payment for a clinical episode of care, based on the expected costs of all items and services provided during the episode. Aims to reduce Medicare expenditures while maintaining or improving quality of care. Participants in this model include rural hospitals.
  • Emergency Triage, Treat, and Transport (ET3) Model – ongoing
    Permits ambulance care teams to use alternate models of emergency health care, such as telehealth treatment and transport to alternative destinations, to improve quality and lower costs of care. Rural Medicare-enrolled suppliers or hospital-based ambulance providers without current medical dispatch and/or telehealth are eligible to participate.
  • Integrated Care for Kids (InCK) Model – ongoing
    A child-centered local service delivery and state payment model aimed at reducing expenditures and improving the quality of care for children covered by Medicaid and the Children’s Health Insurance Program (CHIP) through prevention, early identification, and treatment of priority health concerns. The goals of the InCK Model are to improve child health, reduce avoidable inpatient stays and out-of-home placements, and create sustainable alternative payment models (APMs). Participants include providers serving rural populations in Illinois, Ohio, and Oregon. Integrated Care for Kids (InCK) Model Evaluation: Report 1 profiles each InCK award recipient and presents findings from the 2020-2021 pre-implementation period.
  • Making Care Primary (MCP) Model – announced, accepting applications
    Provides a pathway for primary care clinicians with varying levels of experience in value-based care to gradually adopt prospective, population-based payments while building infrastructure to improve behavioral health and specialty care integration and enhance equitable access to care. Participants can choose to participate in one of three progressive tracks, including one track specifically for organizations with no prior value-based care experience. The MCP model builds upon previous primary care models, including the Comprehensive Primary Care (CPC), CPC+, and Primary Care First (PCF) models, as well as the Maryland Primary Care Program. Launching July 1, 2024, this 10.5-year model will be available in eight states: Colorado, Massachusetts, Minnesota, New Mexico, New Jersey, New York, North Carolina, and Washington. Rural Health Clinics are not eligible to participate in the MCP Model.
  • Medicare Diabetes Prevention Program (MDPP) Expanded Model – ongoing
    A structured behavior change intervention that aims to prevent the onset of type 2 diabetes among Medicare beneficiaries with an indication of prediabetes.
  • Primary Care First Model Options – ongoing
    A set of five voluntary payment model options with the aim of rewarding value and quality through innovative payment structures while emphasizing the doctor-patient relationship supporting advanced primary care. Offered in 26 regions. The Primary Care First Model’s Seriously Ill Population component did not begin on the anticipated April 2021 start date and is currently under review. Evaluation of the Primary Care First Model: First Annual Report, published in December 2022, reports on the first performance year of the Cohort 1 practices.
    • Cohort One – ongoing
    • Cohort Two – ongoing
  • Value in Opioid Use Disorder Treatment Demonstration – ongoing
    Creates two new payments for opioid use disorder (OUD) treatment services, a per beneficiary per month care management fee and a performance-based incentive, with the goal of increasing access to OUD treatment, improving health outcomes, and to the extent possible, reducing costs.

Completed Rural and Rural-Relevant Demonstrations

  • Comprehensive Primary Care Plus (CPC+)
    Focused on improving the quality, accessibility, and efficiency of primary care through regionally-based multi-payer payment reforms and care delivery transformation. Provided participants with technical assistance and up-front enhanced payments as a way to promote practice building capabilities. Providers participated in one of two tracks depending on their existing care delivery activities. Both tracks qualified as Advanced Alternative Payment Models under the Quality Payment Program (QPP). Performance periods concluded December 31, 2021. The Independent Evaluation of Comprehensive Primary Care Plus (CPC+): Fourth Annual Report discusses the first four program years of the model, including practice changes and outcomes for Medicare fee-for-service beneficiaries.
  • Next Generation ACO Model
    An initiative for ACOs experienced in coordinating care for populations of patients. Allowed higher levels of financial risk and reward than available under the Medicare Shared Savings Program. The Fifth Evaluation Report: Next Generation Accountable Care Organization Model Evaluation discusses changes to the model in response to the COVID-19 pandemic and presents findings on the model's impact through 2020. Ended December 31, 2021.
  • Transforming Clinical Practice Initiative (TCPI)
    Supported clinician practices in sharing, adapting, and further developing comprehensive quality improvement strategies. The Practice Transformation Networks (PTNs) provided technical assistance and peer-level support and were required to recruit clinicians serving rural and medically underserved communities and small rural practices. The Support and Alignment Networks involved national and regional professional associations and public-private partnerships and supported the recruitment of clinician practices serving small, rural, and medically underserved communities. The initiative concluded September 28, 2019. Clinical practice transformation tools and resources developed through the initiative continue to be available.
  • Medicare ACO Track 1+ Model
    Qualified as an Advanced Alternative Payment Model (APM), sought to encourage more small practices and hospitals to transition to performance-based risk. Incorporated elements of Track 1 and Track 3 of the Medicare Shared Savings Program, and tested a payment design with more limited downside risk than in Track 2 or Track 3. Ended December 31, 2018; participants could elect to extend through June 30, 2019.
  • ACO Investment Model (AIM)
    AIM funding was for accountable care organizations (ACOs) participating or seeking to participate in the Medicare Shared Savings Program. Tested the use of pre-paid shared savings to encourage new ACOs to form in rural and underserved areas and to encourage current Medicare Shared Savings Program ACOs to transition to arrangements with greater financial risk. Ended December 31, 2018. Lessons learned about advanced payments from AIM informed the incorporation of advanced payments into the Shared Savings Program for Calendar Year 2023.
  • Health Care Innovation Awards (HCIA)
    Tested a wide range of innovative projects to deliver better health, improved care, and lower costs via Medicare, Medicaid, and the Children's Health Insurance Program (CHIP), particularly for beneficiaries with the highest healthcare needs. Included projects that serve rural populations. Ended September 1, 2017.
  • State Innovation Models (SIM)
    Supported statewide healthcare system transformation. Aimed to create multi-payer models that raise community health status and reduce long-term health risks for beneficiaries. Statewide approaches included rural areas, although few included a particular rural focus.
  • Frontier Extended Stay Clinics (FESC)
    An enhanced clinic model in frontier areas to address the needs of seriously ill or injured patients who cannot be transferred to a hospital, or who need monitoring and observation for a limited period of time. Ended April 15, 2013.
  • Medical Assistance Facilities (MAF)
    A Montana demonstration program aimed at preserving healthcare access in frontier areas by converting full-service hospitals into low-intensity, short-stay healthcare service centers. Authorized by the Montana State legislature in 1987, with a Health Care Financing Administration (HCFA, the precursor to CMS) Medicare reimbursement waiver through 1993. Along with the Rural Primary Care Hospital (RPCH) program, a precursor to the Critical Access Hospital program. For more information:
  • Essential Access Community Hospital/Rural Primary Care Hospital (EACH/RPCH) Program
    Enacted by the Omnibus Budget Reconciliation Act of 1989, this program recognized a limited-service facility, the Rural Primary Care Hospital, and linked each RPCH into a network tied to a larger supporting Essential Access Community Hospital. Along with the Medical Assistance Facilities (MAF) program, a precursor to the Critical Access Hospital program. For more information: