For a model of ef­fi­ciency and high-qual­ity care, look at the per­for­mance of ru­ral hospi­tals

Modern Healthcare - - COMMENT - By Alan Mor­gan In­ter­ested in sub­mit­ting a Guest Ex­pert op-ed? mod­ern­health­ View guide­lines at Send drafts to As­sis­tant Manag­ing Ed­i­tor David May dmay@mod­ern­health­ at

It has been al­most two years since HHS Sec­re­tary Sylvia Mathews Bur­well an­nounced in a meet­ing with con­sumers, in­sur­ers, providers and busi­ness lead­ers the goal of shift­ing in­creas­ing per­cent­ages of Medi­care re­im­burse­ments from vol­ume to value.

Ru­ral providers were not in­vited to this ini­tial HHS meet­ing (both lit­er­ally and fig­u­ra­tively speak­ing.) Let’s be frank here. Omit­ting ru­ral health from the na­tional qual­ity dis­cus­sion is a “never event.” As a re­sult, small ru­ral hospi­tals and health clin­ics ap­peared to be left off the trans­for­ma­tion train as it de­parted the sta­tion.

How­ever, full credit must be given to lead­er­ship at the CMS, who moved quickly to mod­ify ex­ist­ing reg­u­la­tions where needed, and in­clude ru­ral providers in new pay­ment demon­stra­tions. What have we learned in the past two years from our lim­ited per­spec­tive re­gard­ing ac­cess, qual­ity and trans­for­ma­tion in a ru­ral set­ting?

Ru­ral and small prac­tices have shown great suc­cess in the Medi­care Shared Sav­ings Pro­gram, or MSSP. The Ad­vance Pay­ment ACO Model sup­ported 35 ac­count­able care or­ga­ni­za­tions made up of small, in­de­pen­dent prac­tices and ru­ral providers. The 35 ACOs in the ad­vance pay­ment model con­sti­tute only 5% of the MSSP par­tic­i­pants, but con­trib­uted 22% of all sav­ings, ac­cord­ing to pub­lished CMS data on the ACOs.

Av­er­age an­nual sav­ings for these ACOs was al­most twice all MSSP mem­bers, and sav­ings per ben­e­fi­ciary per year were more than four times higher.

To­day, 26 ru­ral ACOs are im­prov­ing care and low­er­ing costs un­der the ACO In­vest­ment Model, the sec­ond gen­er­a­tion of the ad­vance pay­ment model. Twenty-three of these ACOs are op­er­at­ing un­der Car­a­van Health’s Na­tional Ru­ral ACO pro­gram, which is now in its third year in the MSSP. Those 23 ACOs in­clude more than 6,000 clin­i­cians in 159 un­af­fil­i­ated ru­ral health sys­tems cov­er­ing 55 ru­ral hospi­tals, 92 crit­i­cal-ac­cess hospi­tals, 168 ru­ral health clin­ics and 39 ru­ral fed­er­ally qual­i­fied health cen­ters serv­ing more than 500,000 Medi­care pa­tients.

These ded­i­cated ru­ral providers are bend­ing the cost curve while strength­en­ing the fi­nan­cial health of their or­ga­ni­za­tions. In 2015, the first Car­a­van Na­tional Ru­ral ACO im­proved its qual­ity score from 69% to 97% in one year and the av­er­age sav­ings for the five ru­ral 2015 MSSP or­ga­ni­za­tions was more than $1.1 mil­lion, 3.8 times higher than the av­er­age for all 2015 MSSP par­tic­i­pants.

The ev­i­dence clearly shows that small and ru­ral prac­tices are suc­cess­ful in im­prov­ing care and low­er­ing costs and even out­per­form­ing their ur­ban peers. They are nim­ble and ded­i­cated to the care of their com­mu­ni­ties.

The data on ru­ral qual­ity are not lim­ited to ba­sic pri­mary care.

Dur­ing last month’s NRHA An­nual Crit­i­cal Ac­cess Hos­pi­tal Con­fer­ence, Dr. An­drew Ibrahim pre­sented data on ru­ral qual­ity sur­gi­cal out­comes, from his May 2016 JAMA ar­ti­cle “As­so­ci­a­tion of hos­pi­tal crit­i­cal ac­cess sta­tus with sur­gi­cal out­comes and ex­pen­di­tures among Medi­care ben­e­fi­cia­ries.”

Ac­cord­ing to his data, ru­ral hospi­tals have com­pa­ra­ble qual­ity out­comes, de­liv­ered at a lower cost. Not sur­pris­ingly, Ibrahim ini­tially thought that he had his re­sults back­wards. Who can blame him? Many have bought into the myth that qual­ity can only be found in large ur­ban med­i­cal cen­ters.

There is a cau­tion­ary note within this trans­for­ma­tion oc­cur­ring in ru­ral Amer­ica: At a time when the data show that ru­ral health­care is head­ing where HHS wants to go, we are also in the midst of a ru­ral hos­pi­tal clo­sure cri­sis. At the cur­rent rate of clo­sure, 25% of all ru­ral hospi­tals will shut down in less than 10 years if Congress does noth­ing. H.R. 3225, the Save Ru­ral Hospi­tals Act, seeks to not only sta­bi­lize ex­ist­ing ru­ral hospi­tals but also pro­vide for a new model and fund­ing for more ru­ral hospi­tals in un­der­served ar­eas to make the suc­cess­ful trans­for­ma­tion from vol­ume to value.

As we move for­ward, the data clearly demon­strate that de­spite an older, sicker, poorer pa­tient pop­u­la­tion, ru­ral hospi­tals have a strong track record of do­ing more with less and demon­strat­ing high- qual­ity out­comes.

Alan Mor­gan is CEO of the Na­tional Ru­ral Health As­so­ci­a­tion.

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