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, and
  • improve population health

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 and Medicaid Services (CMS) Innovation Center was established through the Affordable Care Act. It tests new payment and service delivery models that may cost less while providing the same quality of care. A June 2012 policy brief from the National Advisory Committee on Rural Health and Human Services, Rural Implications of the Center for Medicare and Medicaid Innovation, discusses the potential for CMS demonstrations to address rural needs and offers recommendations specific to rural demonstrations.

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.

Current and Recent Rural Demonstrations

Two new rural healthcare delivery models tested by the Center for Medicare and Medicaid Services (CMS) and supported by the Federal Office of Rural Health Policy (FORHP):

  • Frontier Extended Stay Clinics (demonstration complete)
    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.
  • Frontier Community Health Integration Program (ongoing)
    Developing and testing 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.

Additional rural-relevant demonstrations being tested by CMS:

  • Rural Community Hospital Demonstration (ongoing)
    Cost-based reimbursement for small rural hospitals too large to be Critical Access Hospitals. Examines the community benefits and financial impact for participating hospitals.
  • Health Care Innovation Awards  (ongoing)
    Tests 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. Includes projects that serve rural populations.
  • State Innovation Models (ongoing)
    Support for statewide healthcare system transformation.  Aims to create multi-payer models that raise community health status and reduce long term health risks for beneficiaries. Statewide approaches include rural areas, although few include a particular rural focus.
  • ACO Investment Model (ongoing)
    AIM funding is for accountable care organizations (ACOs) participating or seeking to participate in the Medicare Shared Savings Program. Tests 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.
  • Transforming Clinical Practice Initiative (ongoing)
    The initiative supports clinician practices in sharing, adapting, and further developing comprehensive quality improvement strategies. The Practice Transformation Networks (PTNs) provide technical assistance and peer-level support. They are required to recruit clinicians serving rural and medically underserved communities and small rural practices. The Support and Alignment Networks will involve national and regional professional associations and public-private partnerships currently working in practice transformation efforts. They will especially support the recruitment of clinician practices serving small, rural, and medically underserved communities. The Federal Office of Rural Health Policy hosted an April 21, 2016 webinar on the TCPI model with representatives from the Centers for Medicare & Medicaid Services and two of the PTNs. The webinar recording and presentation slides are available.

The White House Rural Council leads the Rural Impact initiative, a public-private partnership to address rural child poverty that is testing innovative service delivery models:

The Department of Veterans Affairs (VA) has a rural-relevant pilot program underway:

  • Project ARCH (ongoing)
    Project ARCH (Access Received Closer to Home) intends to improve healthcare access for eligible veterans who live near one of the project’s 5 pilot sites and far from a VA health care facility. Pilot sites are located in Northern Maine; Farmville, Virginia; Pratt, Kansas; Flagstaff, Arizona; Billings, Montana.