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Rural Healthcare Quality

According to the Institute of Medicine (IOM), quality is:

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Because quality is directly linked to desired health outcomes, healthcare payers are increasingly using quality measures as a factor in determining provider reimbursements.

The 2001 IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, (Free, registration required.) called for fundamental reform of the U.S. healthcare system to better achieve higher quality standards. This report identified six aims that have been at the heart of U.S. healthcare quality improvement efforts since its release:

  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

The 2005 IOM report, Quality Through Collaboration: The Future of Rural Health Care, argued that rural healthcare has largely been on the periphery of national healthcare discussions, saying:

“In general, the smaller, poorer, and more isolated a rural community is, the more difficult it is to ensure the availability of high-quality health services.”

Although many efforts have been undertaken to improve the quality of care in rural areas since the writing of the report, there are still concerns that rural providers are often left out of major federal quality initiatives.

Frequently Asked Questions

Who monitors the quality of care given by healthcare providers?

There are several organizations that monitor healthcare providers and others that set the standards for quality healthcare. Some organizations do both.

The Centers for Medicare and Medicaid Services (CMS), the country’s largest healthcare payer, has established many initiatives that drive healthcare quality improvement. Types of CMS quality programs include:

  • Public reporting
  • Pay-for-reporting
  • Value-based purchasing
  • Shared savings

CMS administers a variety of public reporting programs that inform consumers on how well healthcare facilities and physicians provide recommended care to their patients. Since consumers are then able to make healthcare decisions based on the data, healthcare facilities have strong incentives to provide high quality care. CMS public reporting programs include:

These reporting programs are voluntary, but there are financial incentives for many providers for participation. Reporting rates vary by state, tool, and individual measure.

Critical Access Hospitals do not have financial incentives attached to participation in CMS public reporting programs, but according Hospital Compare Quality Measure Results for CAHs, 2016, the 2016 Critical Access Hospital (CAH) national participation rate in Hospital Compare was 85.6% for inpatient measures and 60.2% for outpatient measures.

See CMS Quality Initiatives - General Information for an overview of their quality programs. For specific information about each initiative, see CMS Quality Measurement Programs Characteristics.

Although these quality monitoring efforts are impactful for rural healthcare, they are often not tailored to rural facilities and providers. The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement activity specific to Critical Access Hospitals (CAHs) supported through the Medicare Rural Hospital Flexibility (Flex) grant program. Participating hospitals voluntarily share quality data to drive quality improvements based on those data.

Rural health networks, such as statewide CAH quality networks, can voluntarily organize themselves to work collaboratively to improve healthcare quality. Quality networks share useful information such as best practices to achieve quality outcomes and encourage data reporting by members. Member organizations often submit quality data to be analyzed and benchmarked against network, state, and national aggregates to inform quality improvement efforts at each member facility. An example of such a network is the Michigan Critical Access Hospital Quality Network (MICAH QN). Since 2003, CAHs in Michigan have voluntarily united to collectively analyze quality data to inform their processes.

What are the standards of care by which quality is measured?

Many standards exist for providing quality healthcare in the U.S. The National Quality Forum (NQF) is a leader in the measurement of healthcare quality. NQF-endorsed measures are used to quantify and monitor healthcare processes, outcomes, patient experience and perception, as well as organizational structure or healthcare systems. These evidence-based metrics are used by hospitals, healthcare systems, and government agencies such as the Centers for Medicare & Medicaid Services.

How do the Centers for Medicare & Medicaid Services incentivize providers to meet quality standards?

With the passage of the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) has been shifting hospital payments from volume to value. This is done by connecting payments to quality measures of three domains:

  • Process of Care
    Aims to capture the timeliness and effectiveness of care provided at a hospital by collecting data on 13 clinical guidelines.
  • Patient Satisfaction
    To capture patient satisfaction with care, CMS uses the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey, a 32-question survey given to patients to evaluate their experience.
  • Outcomes
    Measures the mortality rate of Medicare patients admitted for heart attack, heart failure, or pneumonia, in addition to infections associated with certain hospital procedures.

The process of shifting from volume to value will occur over multiple years. Rural PPS hospitals are eligible to participate in hospital value-based purchasing if they meet the minimum number of cases and measures. To read more about the measures and their respective implementation dates, see QualityNet.

The Readmissions Reduction Program is another program established by the Affordable Care Act with the aim of reducing payments to hospitals with excess readmissions. Readmission reduction is incentivized by adjusting reimbursement rates from CMS to penalize hospitals with high rates of readmissions.

Critical Access Hospitals are not eligible to participate in either the hospital value-based purchasing or the readmission reduction program. In 2014, the National Quality Forum (NQF) developed a workgroup, funded by the U.S. Department of Health and Human Services to provide recommendations concerning healthcare quality measurement issues for rural and low-volume healthcare providers. The final report, Performance Measurement for Rural Low-Volume Providers, included 14 recommendations that could ease the transition to value-based purchasing for rural providers.

How can I find out how well my state is doing regarding healthcare quality?

The Agency for Healthcare Research and Quality (AHRQ) produces the National Healthcare Quality Report, using performance measures to monitor the nation's progress toward improved healthcare quality for all Americans. This annual report shows the rankings of states on these measures and compares states to national averages on each of the selected measures. This report also includes a State Snapshots series which provides state-specific healthcare quality information depicting strengths, weaknesses, and opportunities for improvements for each state.

Rural-specific quality reporting can be challenging to find due to low volumes, as well as the fact that reporting is voluntary for CAHs, but some organizations focus on analysis of rural-specific quality data. The Flex Monitoring Team, for example, is funded by the Federal Office of Rural Health Policy to analyze and evaluate the Medicare Rural Hospital Flexibility Grant Program. It produces annual quality reports for each of the 45 states participating in the Flex Program. State-level reports for 2017 and 2018 include voluntarily reported data by Critical Access Hospitals (CAHs) across the country and compare CAH reporting and results by state across a variety of inpatient and outpatient quality measures. Two national summary reports, Hospital Compare Quality Measure Results for CAHs, 2016 and Patients’ Experiences in CAHs: HCAHPS Results, 2016, are also available.

Many sources of rural-relevant statistics, including quality measures, can be found on RHIhub’s Finding Statistics and Data Related to Rural Health topic guide.

Is there research that focuses specifically on rural healthcare quality?

The Federal Office of Rural Health Policy (FORHP) supports a number of rural health research centers that conduct a variety of research, including studies of rural healthcare quality. The Rural Health Research Gateway is funded by FORHP to disseminate the publications developed by the rural health research centers. Research specific to rural health quality can be found on the Rural Health Research Gateway’s Quality topic page.

How is healthcare quality assured?

State regulatory agencies license healthcare providers. They also survey and certify healthcare organizations for participation in the Medicare program to ensure the delivery of safe care and compliance with Medicare conditions of participation. Healthcare facilities can voluntarily choose to be reviewed for accreditation by an independent accreditation organization (AO), such as the Joint Commission. Accreditation by an AO exempts the facility from state surveys to determine Medicare compliance. Rural hospitals are less likely to seek accreditation from an AO than their urban counterparts and often choose instead to be federally certified through state survey processes. To read more, see Accreditation on the CMS website.

Additionally, Quality Improvement Organizations (QIOs) are independent organizations that work on behalf of the Centers for Medicare & Medicaid Services (CMS) to improve healthcare quality. QIOs work with healthcare facilities and providers to improve healthcare delivery to ensure quality care, especially for underserved communities. QIOs also make sure Medicare payment is made for only medically necessary services and investigate complaints made by beneficiaries concerning quality of care. Although QIOs have been around since 1984, on August 1, 2014, CMS began a new contract cycle with notable changes. The work of QIOs is now state-focused under regionalized contracts with two Beneficiary and Family Centered Care-QIOs (BFCC QIOs) and 14 Quality Innovation Network (QIN QIOs). To read more about QIOs, see Quality Improvement Organizations.

Are all hospitals required to report to CMS on quality measures in order to maximize their reimbursement through the Medicare program?

Hospitals paid through the prospective payment system (PPS) are required to report quality measures to CMS in order to maximize their reimbursement. PPS hospitals are now subject to penalties and bonus payments from CMS in relation to the Hospital Value-Based Purchasing Program and the Readmissions Reduction Program.

Critical Access Hospitals (CAHs) are encouraged to voluntarily report to CMS but it does not affect their reimbursement. The Medicare Rural Hospital Flexibility Grant Program, designed to support rural hospitals with CAH designation, encourages quality and performance improvement activities. The Medicare Beneficiary Quality Improvement Project (MBQIP) is a special project of the Rural Flexibility Grant Program and supports CAH reporting to CMS as a means to help improve quality of care.

What challenges exist that make it difficult to compare quality of rural healthcare to urban health?

Fundamental differences in how healthcare is provided between rural and urban settings, as well as socioeconomic and cultural differences of the populations served, make it challenging to compare healthcare quality. Understanding these differences is one of the greatest challenges to comparing quality outcomes.

These differences were highlighted by formal responses to a 2013 JAMA article, Mortality Rates for Medicare Beneficiaries Admitted to Critical Access and Non–Critical Access Hospitals, 2002-2010. The article garnered formal response by the Flex Monitoring Team and two informal responses by Dr. Wayne Myers in the Daily Yonder and the Rural Monitor.

As summarized in the Flex Monitoring Team response, understanding the rural context is key:

“Researchers who analyze rural health policy issues need to understand the rural health care environment. If not, their research has the potential to harm rather than help rural hospitals and health care professionals in providing high-quality care for their patients.”

Key differences highlighted in the responses to the article include:

  • Differences in volume and services
    Rural healthcare facilities see a much smaller volume of patients than their urban counterparts, making it a challenge to compare quality between the two types of facilities. With a small sample size for any one procedure or treatment, quality data can be skewed, leaving a high probability of misinterpretation. Due to their small size and remote nature, CAHs often don’t offer the advanced procedures available at larger urban facilities. For example, few rural hospitals provide cardiac catherization; they instead focus on stabilization and transfer of patients in need of such services.
  • Differences in patient demographics and choices
    Patients have a choice in how they receive care and their preferences can directly contribute to quality outcomes. A patient may choose to be treated near their home at a rural facility, knowingly forgoing a higher level care which could be provided at a larger facility. In some instances, rural patients may use rural hospitals as a proxy for hospice services so they can be near their home and family at the end of their life.
  • Differences in transfer rates
    Small rural hospitals transfer patients at higher rates than larger facilities, especially for some serious medical conditions such as emergency cardiac care, according to Which Medicare Patients Are Transferred from Rural Emergency Departments? Outcomes of rural hospitals may vary depending on whether transferred patients are excluded, assigned to the initial hospital, or to the receiving hospital.

These challenges have been recognized and some steps are being taken to address them. The National Quality Forum (NQF) has developed a workgroup, funded by the U.S. Department of Health and Human Services, to study concerns related to measuring healthcare quality in rural areas. The workgroup provided recommendations to the U.S. Department of Health and Human Services concerning healthcare quality measurement issues for rural and low-volume healthcare providers. The final report, Performance Measurement for Rural Low-Volume Providers, included 14 recommendations that could ease the transition to value-based purchasing for rural providers. Recommendations fell into the following categories:

  • Development of rural-relevant measures
  • Alignment of measurement efforts
  • Measure selection
  • Pay-for-performance considerations

What are some emerging service delivery models aimed to increase healthcare quality?

Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) are two noteworthy service delivery models that aim to improve healthcare quality through a value-based, rather than volume-based, strategy. Both models aim to improve outcomes by more closely coordinating care among providers and facilities to improve quality outcomes.

ACOs are groups of physicians, facilities and other healthcare providers who voluntarily enter into a partnership to provide coordinated care with incentives for quality and efficiency. As an incentive to provide high quality care, the Centers for Medicare & Medicaid Services (CMS) and some commercial payers will share cost savings with the ACO. The ACO Investment Model is an ACO initiative established by CMS in 2015 to encourage participation among rural providers. This model was developed in response to concerns over small and rural providers lacking the adequate resources to establish the necessary infrastructure for successfully implementing a population care management program. To read more, see ACO Investment Model.

The patient-centered medical home (PCMH) is a model for providing patient care that is comprehensive, patient-centered, coordinated, accessible, and high quality. This model emphasizes a long-term relationship between the patient and a team of professionals, led by the patient’s physician, which works to provide and coordinate care. Despite challenges to implementing the PCMH model in rural areas, optimism exists for its ability to achieve financial savings and reach quality improvement targets in rural areas, according to Rural Health Clinic Readiness for Patient-Centered Medical Home Recognition: Preparing for the Evolving Healthcare Marketplace.

To read more about the impact of these and other emerging service delivery models on rural healthcare see Rural Care Coordination.

How can the use of telehealth and HIT impact the quality of care delivered in rural areas?

Telehealth and HIT are technology-based tools that can improve care and care coordination in rural communities. These technologies can play a significant role in improving quality of care in rural communities. For more information, see RHIhub’s topic guides on Telehealth Use in Rural Healthcare and Rural Health Information Technology.

Last Reviewed: 1/25/2016