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
The Centers for Medicare & Medicaid Services (CMS) Innovation
was established through the Affordable Care Act. The 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.
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
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
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. In 2019, HRSA awarded three-year grants to recipients in 21 states 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 2021, HRSA awarded 9
additional grants to recipients in 7 states.
Rural-Specific Demonstrations Being Tested by CMS
Community Health Access and Rural
Transformation (CHART) Model – ongoing
This rural-focused initiative includes two tracks for participation. The Community Transformation Track will
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. In February 2022, CMS announced it removed the previously-publicized Accountable Care Organizations
(ACO) Transformation Track from the CHART Model.
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
Appropriations Act, 2021, authorized a five-year extension period for participating Critical Access
Hospitals beginning on July 1, 2021.
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
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: Implementation Report describes the first two years of the
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: Report Covering 2005-2017 (Interim Report 1), issued in
September 2021, discusses the first twelve years of the demonstration and the impact of the program on
Rural-Relevant Demonstrations Involving Accountable Care Organizations (ACOs)
Additional Rural-Relevant Demonstrations Being Tested by CMS
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.
Professional Direct Contracting (GPDC) Model – ongoing
A set of two voluntary payment model options that were introduced to innovate Medicare fee-for-service
(FFS) approaches to produce value and high-quality care outcomes. The goal of this model is to reduce
burden, support a focus on beneficiaries with complex, chronic conditions, and encourage participation from
organizations that have not typically participated in Medicare FFS or CMS Innovation Center models.
In February 2022, CMS announced it redesigned the GPDC Model, which will transition to the Accountable Care Organization Realizing
Equity, Access, and Community Health (ACO REACH) Model beginning January 1, 2023. Changes were made
to the GPDC Model for ACO REACH to emphasize health equity, leadership and governance, and model
transparency. GPDC Model participants may continue to participate in the ACO REACH Model if they maintain a
strong compliance record and agree to meet all the ACO REACH Model requirements.
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.
Care for Kids (InCK) Model – participants announced
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.
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.
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.
Cohort One – ongoing
Cohort Two – announced
State Innovation Models
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.
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.
The Rural Impact initiative, a public-private partnership to address rural child poverty that is testing
innovative service delivery models:
Completed Rural and Rural-Relevant Demonstrations
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
Next Generation ACO
An initiative for ACOs experienced in coordinating care for populations of patients. Allowed higher levels
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
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.
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 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.
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.
Frontier Extended Stay Clinics
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 health care 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. 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. For more information: