In rural communities, the manner in which healthcare is
delivered is often dependent on the financial position of
the local healthcare facilities. With limited resources
and staff, rural hospitals and clinics are examining the
various forms of Delivery System Reform (DSR) they can
implement to remain viable in a changing industry. This
was a widely discussed topic at the September
meeting of the National Advisory Committee on Rural
Health and Human Services (NACRHHS) in Mahnomen,
Much of DSR is centered around the
Triple Aim, a concept developed by the Institute for
Healthcare Improvement. This three-pronged approach is
Improving the experience of care for individuals
Improving the health of populations
Lowering per capita healthcare costs
Recently, Health and Human Services Secretary Burwell
outlined tangible steps to achieving the Triple Aim
by tying Medicare payments to quality outcomes or value
through alternative payment models, such as Accountable
Care Organizations (ACOs) and bundled payment
At the NACRHHS meeting, it was recognized that the
participation of rural providers in DSR is important,
despite challenges and barriers rural communities face.
Rural regions are often at a disadvantage for
implementing DSR. Statutory exclusions pose a barrier to
DSR, as participation in the Medicare Shared Saving
Program requires a certain number of beneficiaries, which
inherently excludes low-volume networks of providers.
Similarly, quality measures to which payments are tied
need to be examined in order to better reflect the nature
of care provided in rural locations; otherwise wrongful
conclusions may be drawn about the quality of care.
“Measurement is paramount to assuring and
demonstrating value,” said Jennifer Lundblad,
President and CEO of Stratis Health.
The committee discussed the importance of the recent work
National Quality Forum Rural Health Committee in
highlighting the challenges and potential solutions that
would allow rural facilities and practices to engage in
quality improvement and pay-for-performance programs.
Workforce shortages, both in terms of number of providers
and specialties represented, make it difficult for rural
facilities to meet DSR objectives and the quality
standards attached to payments.
It's been said that form follows function. In
healthcare, function and form follow finance.
Limited financial resources also put rural communities on
unequal footing, as system reform requires an investment.
With smaller budgets and profit margins, rural facilities
often need more assistance during the implementation of
these new programs.
“It's been said that form follows function. In
healthcare, function and form follow finance,”
stated Paul Moore, Senior Advisor at the Federal Office
of Rural Health Policy.
With the right incentives and the ability to share
patient information, healthcare access and quality could
be improved, resulting in better outcomes.
During the NACRHHS meeting, participants acknowledged
that much is happening with rural DSR despite the
challenges in both the public and private sectors. In the
public sector, new payment models (particularly the ACO
Investment Model), patient-centered medical homes, State
Innovation Model (SIM) programs, community transformation
grants, value-based purchasing practices, and workforce
initiatives are all underway and attempting to improve
rural care. In the private sector, payer-provider
contracts for accountable care, patient-centered care
teams, and other initiatives have been implemented to
increase access to quality care.
From the information gleaned from the speaker
presentations and site visits to healthcare facilities in
Detroit Lakes and Fergus Falls, Minnesota, the committee
will make recommendations to Secretary Burwell to better
address the challenges of DSR in rural areas.
The committee's discussion looked at policy solutions
that could help rural facilities succeed as DSR moves
Mandatory participation in CMS quality improvement
programs through a phased approach
Further development of rural-relevant quality
measures that are tied to reimbursement
Encouraging voluntary groupings of rural providers
for payment incentives
Throughout the meeting, it was reiterated that care
delivery redesign is necessary, and that the
opportunities are far-reaching. To make these new
delivery models successful, however, effective care
coordination is essential.