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 bene-ficiary 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.
