Author Archive: Lynn Barr

AHRQ Says Rural Quality is Subpar

So one of the debates out here is how does rural score in quality? Well, according to AHRQ’s Chartbook on Rural Health, not too good. The AHRQ publication released in August 2015 explains that rural counties report “worse” in the four of five NQF priorities: effective treatment, patient safety, healthy living and access when compared to their urban counterpart. Rural scores the “same” in patient centeredness but on no occasion does rural score “better”. In fact the more rural you get, the worse the quality scores. This is not good news for rural providers given the increasing reporting requirements on the horizon.

How does rural score on hospitalizations due to ambulatory care-sensitive conditions (ACSCs) such as hypertension and pneumonia that can be largely prevented if ambulatory care is provided in a timely and effective manner? You guessed it, not too good. According to the report, the rate of potentially avoidable hospitalizations for all conditions for people living in rural counties was higher than for residents living in metropolitan areas.

Same thing with Emergency Department utilization, the further you get away from the city the more people use the ED. AHRQ reports that the rate of ED visits per 100,000 was higher for rural residents when compared with urban. ED visits are costly and may be indicative of poor care management, inadequate access to care, or poor choices on the part of beneficiaries. ED visits for conditions that are preventable or treatable with appropriate primary care lower health system efficiency and raise costs.

This data is very representative of what we see in our NRACO data and it is driving our services. Understanding your quality scores in preparation for value-based payment models must be a priority for all rural healthcare providers. How do you score?


by Sue Deitz, MPH, Regional VP, National Rural ACO

Read Our November Care Coordination Newsletter

Escalating medication costs are of concern for consumers and providers of healthcare.  In our November Care Coordination Newsletter, read about the innovation of one Community Care Coordinator who is helping her patients maximize Medicare Part D benefits and other innovative medication assistance programs to achieve affordable options for successful medication management.

Click here  to read the November issue of Care Coordination newsletter.

National Quality Forum Calls for Mandatory Quality Reporting for Rural Providers

Participation in CMS quality measurement and quality improvement programs is mandatory for all rural providers”, according to a report released by the National Quality Forum’s Rural Health Committee. The NQF report, Performance Measurement for Rural Low-Volume Providers, outlines recommendations that transition rural providers into value based purchasing and is further evidence that rural performance measurement is here to stay. It is no longer a choice. Secretary Burwell’s laid the track when she announced that 30% of all Medicare provider payments will be tied to alternative payment models (e.g., accountable care organizations (ACOs), primary care medical home (PCMH) models, bundled payment arrangements, etc.) by the end of 2016 (50 percent by the end of 2018). HHS also seeks to tie 85 percent of Medicare fee-for-service payments to quality by 2016 (90 percent by 2018) through programs such as the Hospital Value-Based Purchasing and the Hospital Readmissions Reduction Program.

You can view the report here. 

The recommendations in the NQF report furthered our dialog of how we can accomplish Secretary Burwell’s goal given the challenges faced by the rural providers. Specifically, the report called for the need for rural-relevant measures that a can address low case volume explicitly and consideration of a sociodemographic risk adjustment It proposed the use a core set of measures, along with a menu of optional measures for rural providers and encouraged the measures that are used in patient-centered medical home models. It recommended performance be tied to incentive payments, not penalties. And most striking was the accelerated timeframe with the creation of incentive-only payment programs for rural providers within three years; and mandatory participation in CMS quality improvement programs within two to four years.

Rural providers have a legacy of policies and programs that often do not “fit” current local needs and often have misaligned incentives that undermine high-value and efficient care delivery. Cost-based reimbursement, for example, has not created incentives for value-based models that invest less in technology-intensive medical services and more in health promotion, care coordination, improved clinical care quality, enhanced patient safety and experience, and better population health at lower per capita costs. Nonetheless, rural communities have enormous potential for achieving the objectives of the Triple Aim. Smaller systems can be more nimble in making the kind of change necessary to succeed in the current environment.  New delivery arrangements may be pursued more easily among local clinical, behavior and public health providers who know and trust one another. Together, they share a collective interest in improving their community’s well-being. While the transition from the status quo will require a change in the balance and configuration of essential services, greater integration within and across service sectors, attention to population health, and shared governance and management structures, it is doable.   My take away – rural providers can no longer stay idle. The greatest threat to the sustainability of rural healthcare systems is not participating in rural performance measurement. The market will force doctors and patients to choose high value providers and partners – and rural will be left behind.

Summary of Key Rural Provisions in the 2016 Physician Fee Schedule

Following is a summary of the key rural provisions in the 2016 Physician Fee Schedule.

Advanced Care Planning:
CMS is approving new CPT codes 99497 (initial 30 minutes) and 99498  (subsequent 30 minutes) for explanation, discussion and completion of Advanced Directive forms for Medicare beneficiaries. The estimates of payment are $86 in an office setting and $80 in an inpatient setting. While this can now be part of the Annual Wellness Visit or a physician visit, and does qualify as an RHC visit, it cannot be billed in an RHC in addition to the All-Inclusive Rate.

Rural Health Clinics and HCPCS Codes:
RHCs will now be required to record all HCPCS codes for services provided during a visit, even though additional payment will not be forthcoming. It is essential that RHCs completely detail the services they provide. There is much debate about whether RHCs are not providing the same standard of care services as most fee-for-service clinics (such as smoking cessation counseling) or are they simply not documenting them because it does not affect payment. If you are doing the work, make sure you document it, or this could have negative consequences under payment reform. The new requirement for recording the HCPCS codes on the bill has been delayed from January 1st to April 1st 2016.

RHCs and FQHCs can Bill for Chronic Care Management (CCM) Codes:
Beginning in January 2016, RHCs and FQHCs can now bill $41.92 per patient per month under Part B for CCM services outside of the All-Inclusive Rate. Thanks, CMS! You heard our prayers.

New Quality Measure for the Medicare Shared Savings Program:
CMS is adding a new Statin Therapy for the Prevention and Treatment of Cardiovascular Disease in the Preventive Health domain.  The measure reports the percentage of beneficiaries whoe were prescribed or were already on statin medication dureing the measurement year and who fall into any of the following three categories: active diagnosis of clinical atherosclerotic cardiovascular disease, LDL-C > 190 mg/dl, or diabetics with LDL-C of 70-189 mg/dl. This new measure will be pay-for-reporting only for the next three years.

Changes in Assignment of Beneficiaries for the Medicare Shared Savings Program:
Primary care services that are delivered in a Skilled Nursing Facility (POS code 31) will no longer be considered for patient attribution.

To see all of the changes in the PFS, please go to

National Rural Accountable Care Consortium is Awarded TCPI Grant to Support Rural Health

On September 29th, Secretary Burwell announced that our non-profit organization, the National Rural Accountable Care Consortium, was awarded up to $31 million to support 525 rural health systems across the country to prepare for Advanced Payment Models.

Our program is designed to assist rural providers in redesigning their ambulatory practices to maximize their success under the new value-based payment models. We will provide them the tools to set up a Medicare-billable care coordination program. These tools include the necessary IT infrastructure and a 24-hour Nurse Advice hotline. We use data from electronic health records to help providers facilitate and optimize their ambulatory quality scores. They can also use this data to redesign their practice workflow to improve care and lower costs. The Consortium also sets up ambulatory patient satisfaction surveys, engages with  physicians and leadership, and provides guidance on how to participate in and increase revenue through Advanced Payment Models.

We are very grateful for the support that CMS and CMMI is giving rural providers. Working together, we can provide better care for our community, reduce unnecessary costs, and improve the financial performance of our rural health systems. For more information about this program, please see the CMS website.

Click here to apply for the program. 

The project described was supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.  Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or its agencies.

National Rural ACO Featured In HCPLAN Newsletter

I am excited to share this Q&A about the National Rural ACO and our work with ACOs that was recently featured in the HCPLAN Newsletter.

HCPLAN Newsletter | August 12 | Participant Spotlight: National Rural ACO (see pg. 4)

The National Rural ACO pools knowledge, patients, and resources so that independent community health systems can participate in new population health-based reimbursement models. Lynn Barr, MPH, Chief Transformation Officer, spoke with a member of the CAMH team on July 28.

[CAMH]: What is the National Rural ACO’s goal, and what key approaches are you using?

Barr: We focus only on rural communities. Though 20% of Medicare beneficiaries get care in rural America, these health systems are far behind in population health management. Many have not done care coordination, performance measurement, etc. Our goal is to help them make improvements in quality and cost. For example, their aggregate quality scores in 2014 were 60%. We want to get to 70-75% in year two and 80-90% in year three. We also aim to reduce costs by 10% within the first three-year cycle. For 2016, we’re putting in applications to CMS for 26 rural ACOs with 179 health systems in 32 states. Our biggest goal is getting people started on the journey of population health management. We are very excited about that.

Our first step is to set up care coordination in each community. Every member hires a care coordinator. This is great for the patients, and it helps lower costs and improve quality. Second, we add annual wellness visits. A provider can hit 11 quality scores in an annual visit. About 5O% of our members haven’t been doing annual wellness visits. It’s a billing issue. In other fee-for-service clinics, when a patient comes in for a regular visit, the provider can also do the wellness visit and bill for both. Rural providers and Federally Qualified Health Centers aren’t allowed to bill separately. That’s a huge disincentive. The third component is reducing Emergency Department (ED) utilization. Rural beneficiaries use the ED for primary care because rural providers aren’t available 24/7. Fifty percent of rural ED visits are for primary care. Total ED utilization per beneficiary is 20% higher than the national average. We want to bring that down significantly. Another component is analytics. We provide data to support the other three components. It makes a big difference. For example, we found that the cost of home health in one of our ACOs is $1000 per month, while the national average is just $300. There is a great opportunity to make a difference.

[CAMH]: Who can join? Is there a typical profile of a member?

Barr: All our members are “community health systems.” Typically there is one hospital with a group of affiliated physicians. Our goal is to take that delivery network and integrate it with others to improve performance and coordinate care.

[CAMH:] How much variety is there across your ACOs and why?

Barr: Rural providers are very diverse. Our hospitals range from 4 to 250 beds. Our communities have anywhere from 175 to 8,000 attributed patients, with the average being about 1,000 attributed lives.

[CAMH:] To what extent are rural health systems’ challenges unique?

Barr: One of the biggest differences is size. Almost all of these health systems don’t have the minimum 5000 attributed beneficiaries, which is why we need to combine them. They have extremely limited capital; lack of funding is a huge barrier. They also have very little IT infrastructure, so we have to provide it for them. Almost all have electronic health records. Rural providers are right up with the rest of the country for EHR adoption, but their EHRs are very simple. We use the Lightbeam Health population management system to pull all their claims data together with their clinical data. Data is critical. We get It to them quickly and show them how to use it. Their care coordination program is built around claims data.

[CAMH]: Are the components of your ACO approach different from what might work in urban ACOs?

Barr: Yes, they are very different from urban ACOs. The top rural health system concerns are building relationships with patients and building secondary and tertiary networks. They have few or no networks and highly fragmented care. For example, the 175 patients in our smallest community with were seen in 75 different Part A facilities in the last 2 years. Our focus is around engaging the community and, as a result, improving cost and quality. Urban ACO communities are huge. You can’t really understand the concept of community until you live and work in a rural hospital. Everyone shows up for a hospital board meeting and cares about their providers. In small communities, patients have deep relationships with their providers. We can succeed and thrive by serving their needs.

Urban ACOs don’t focus on community per se, because the ACO is just one of many players in town. Their patients change providers more often, so they focus on services they deliver and how to maximize cost and quality improvements. Our biggest advantage is that the patient population tends to be more stable. They may go other places for care, butthey tend to come back home. For example, if we do a good job on colorectal screening, we can wipe outcolorectal cancer in our town. That is very satisfying. Also, our approach wouldn’t work so well in urban settings where there is competition. There isn’t competition among our rural health systems, so it is easier to build collaboration. On the other hand, we are similar to urb an ACOs, insofar as this is a lot of hard work for everyone.

Barr: Our first ACO started in the 2014 performance year. By end of the first year, it had reduced utilization in every category except physician visits. It is too early to tell for the others. We only have 90 days of data so far, but there are some promising trends.

[CAMH] What in your mind are the most important lessons you’ve learned so far about standing up and running ACOs in rural health systems?

Barr: We changed the program quite a bit after the first year. We initially thought start up would be simpler. It takes a lot more interaction than we had assumed. We had to increase staffing to work more closely with each partner. It is more labor intensive, but rewarding. We really appreciate the support we are getting from the CMS Center for Medicare and Medicaid Innovation. We feel that they are committed to helping rural providersand to our success.

Click here to read the full newsletter,

CMMI Alters Rules for the ACO Investment Model — More Rural Health Systems Will Qualify

On June 25th, the Center for Medicare and Medicaid Innovation (CMMI) announced two important changes to the rules for rural providers who are applying for the Medicare Shared Savings Program this year to become ACOs. Click here to read about the two important changes.

They have removed the 10,000 life cap for rural ACOs. This is very important because it is very difficult to estimate how many lives will be attributed to rural ACOs. By removing the cap, many more rural ACOs will qualify.

They are now also providing AIM funding to ACOs that applied in 2015.

Thanks for listening CMMI and CMS! Your support for rural providers is obvious and well-appreciated. Together we will create healthier communities and lower healthcare spending. Now the work begins.

The National Rural ACO: Hundreds of Rural Health Systems, 50 ACOs, and the New World of Value-Based Payments

When we began this journey, our central premise was that every rural community should not have to figure out how to accomplish population healthcare on their own and that the population numbers had to reach enough scale to be affordable. We planned to develop the systems with our pilot group, test our scale up with second year enrollments and be ready to serve the market the third year. Our plan was to have 10 communities in year one, 30 communities in year two and 100 communities in year three. For every 10 communities we brought on board, we would need a project manager and a care coordination coach. We partnered with high-performing rural networks to engage the Executive Directors who lead the ACOs, and provided our own as well. We tested the scale up for 30 communities this year. Our plan worked and we are now ready to scale to the next level to support the 2016 applicants.

We have hired most of our senior staff and are currently refining our programs with the 2015 ACOs. Every member has their data, has hired Care Coordinators and has met with us monthly to work on redesigning the workflows at the clinic to optimize quality and reduce cost. We are constantly learning and sharing best practices across the country. The scale up of ACO Managers and Care Coordination coaches has been successful and can be replicated to meet the demands of our 2016 cohort.

The biggest change to our model in 2016 will be the addition of management and financial consultants to the team. These consultants will work hand in hand with the member’s CFO to ensure a smooth transition to value-based payments. Our 2016 members will get to choose from premier firms such as Alliant, BKD, Blue and Company, Coker, Eide Bailly, HFS Consultants and Quorum to attend steering committee meetings, review member financials monthly and make recommendations to improve performance. Alternatively, members can choose to work with our local network partners such as Hometown Health, Indiana Rural Health Association, Monida Health Network, New Mexico Rural Hospital Network, Northland Health Alliance, Southeast Texas Hospital System, Washington Critical Access Hospital Network, Washington Rural Health Collaborative, and the West Virginia Critical Access Hospital Network.  These partnerships allow us to access local expertise while training our partners in these new programs.

Finally, we have selected four regional Vice Presidents who will serve as the Executive Directors of their ACOs and who will work with our member’s consultants to develop relationships with other payers in their state to implement similar gain-sharing arrangements for their Medicaid and commercial patients.

By leveraging our experience, scale and depth, we are the best opportunity for success in the transformation of your delivery system and preparation for the new world of value-based payments.



Legislative Alert: Senators Thune and Cantwell Introduce Legislation to Allow Patient Assignment to Rural Providers for Medicare Shared Savings Program


Today, rural providers struggle to have the majority of their patients attributed to them for the Medicare Shared Savings Program because the Affordable Care Act requires patients to be assigned based on the plurality of care by a physician.

As a result, rural providers who rely heavily on Nurse Practitioners to deliver care only get about one-third of their patients attributed to them, compared to almost two-thirds of patients attributed to urban providers. This makes it twice as hard for rural providers to qualify for the program and means we get paid half as much for the same work.

Senators Cantwell and Thune have introduced legislation to fix this wording issue in the Affordable Care Act. Please take a moment now to have a member of your staff reach out to your Senator and tell him or her that it is very important to support this bill. It is budget neutral and fair to everyone, including our rural patients.

The Senators’ press release follows below. We really appreciate their support, and especially their comment, ““The rural ACO model has the potential to greatly improve access to high quality care in rural parts of our state.” Yes it does.


WASHINGTON, D.C. – Last Friday, U.S. Senators Maria Cantwell (D-WA), Patty Murray (D-WA) and John Thune (R-SD) introduced bipartisan legislation that would improve Medicare Accountable Care Organizations (ACO’s) for patients and health care providers.

The Rural ACO Improvement Act of 2015 promotes access to coordinated, patient-focused health care services in rural and underserved areas by implementing improvements to the way patients are assigned to the Medicare Shared Savings Program, a key Medicare ACO.  The legislation allows Medicare to include primary care visits by nurse practitioners, physicians’ assistants and clinical nurse specialists, as well as primary care services furnished in Federally Qualified Health Centers and Rural Health Clinics, in assigning patients to an ACO.  The changes aim to make ACO assignment more accurate and inclusive in communities lacking primary care physicians, while enabling health care providers to attain enough ACO participants to make the model successful.

“Washington state has long been an innovator in the delivery of efficient and coordinated health care.” said Cantwell.  “This legislation advances that innovation by promoting health care that puts the health of patients at the forefront, particularly in rural communities that lack primary care physicians.  Improvements to Medicare’s delivery of health services mean higher-quality care for Washington state beneficiaries and lower costs for taxpayers.”
“I’m focused on building a health care system that works for Washington state families, and to do that, we need to make sure that families are able to get high quality care right in their own communities,” said Senator Murray. “Our legislation will help more families in Elma, Shelton, and communities throughout our state benefit from innovative delivery system reforms that are designed to put patients and families first and save taxpayer dollars, by helping to bend the cost curve and improve quality of care.”

“While health care reimbursement models are transforming, it’s important to level the playing field so rural health care organizations can participate in new payment models, like ACOs, that reward well-coordinated, high-quality, low-cost care,”said Thune. “This bipartisan legislation takes several common-sense steps that would not only help rural ACOs get off the ground, but would also result in more coordinated access to value-based rural health care for Medicare beneficiaries across the country.”

“We commend the Senators’ legislation which will ensure those patients who have chosen to receive primary care services from a nurse practitioner are eligible to be included in an ACO,” said Dave Hebert, CEO of the American Association of Nurse Practitioners.  “This change will result in increased access to the quality primary care that nurse practitioners provide especially for those patients in rural and underserved communities.”

“The rural ACO model has the potential to greatly improve access to high quality care in rural parts of our state. But to achieve that goal, it must reflect the realities of who provides care in these communities,” said Scott Bond, CEO of the Washington State Hospital Association. “This bill recognizes the critical role nurse practitioners and physician assistants play in providing access for residents of rural communities.”

Accountable Care Organizations, or ACO’s, are groups of hospitals, doctors, and other health care providers who voluntarily join together to coordinate care for a specific patient population.  In ACO’s, health care providers are responsible for effectively managing the health and wellness of patients: when an ACO delivers high-quality care at a lower cost than traditional fee-for-service spending, the ACO recoups part of the savings.  Created by Congress in 2010, the Medicare Shared Savings Program is a voluntary program enabling health care providers to share savings with Medicare if they beat cost targets and achieve specified quality measures.