National Rural ACO

News, commentary and opinion on the ongoing transformation of our health care systems.

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Read Our February 2016 Care Coordination Newsletter

Quality of Life. We aim to arm Care Coordinators with a tool box of knowledge and resources so that they can provide the best care possible to their patients. Our February Care Coordination Newsletter delves into Chronic Obstructive Pulmonary Disease, covering various adjustments and treatments Care Coordinators can make to ensure patients living with COPD have an improved quality of life. We also share information about the COPD Foundation’s community website, which will provide Care Coordinators with an expanded network of information and support.

Click here to read our February 2016 Care Coordination newsletter.


Rural Providers Organized Under 23 Medicare ACOs Receive $46 Million AIM Funding From CMMI

I would like to share this news release which was released to the news media today.

Lynn Barr

Rural Providers Organized Under 23 Medicare ACOs Receive $46 Million AIM Funding From CMMI

Additional $31 million also provided by CMMI to prepare rural practices for value-based payments under new Practice Transformation Network

Nevada City, CA, January 12, 2016 — A pioneering group of rural physicians and hospital administrators came together in 2013 to begin the journey toward managing rural population health. Through innovation and collaboration, they sought to transform today’s rural healthcare delivery system into a world-class primary care system that provides professional satisfaction for clinicians, attracts consumers, and provides high-quality acute, post-acute and outpatient services that meet patients’ needs.

These rural thought-leaders joined forces to form the first National Rural ACO (NRACO) and create the NRACO Services Corporation (NSC), which has been supporting rural Medicare ACOs with training, data, analytics, patient satisfaction surveys, and evidence-based medicine programs since 2014. In 2015, NSC organized more than 6,000 providers in 159 rural health systems into 23 Medicare Shared Savings Program (MSSP) ACOs, and obtained $46 million in ACO Investment Model funding to support their ACO operations and local care coordination programs. This group includes 55 rural PPS hospitals, 92 Critical Access Hospitals, 168 Rural Health Clinics, and 39 rural FQHCs serving more than 500,000 Medicare patients.

Working with other key stakeholders like the National Rural Health Association and the National Rural Health Resource Center, the rural hospital CEOs also started the non-profit National Rural Accountable Care Consortium. The Consortium will assist hundreds of rural health systems in their journey toward accountable care, funded by a $31 million cooperative agreement award from the Center for Medicare and Medicaid Innovation (CMMI).

To date, the majority of National Rural ACO participants have demonstrated reductions in per capita spending while improving quality and patient satisfaction. Unexpectedly, this has also resulted in financially strengthening the majority of the participating rural health systems. Participating hospital CFOs are queried monthly on the financial status of their organizations, and none have reported negative effects of being associated with accountable care, while most have described increased revenue and improved staff satisfaction.

According to NRACO founding member Tim Putnam, CEO of Margaret Mary Health in Batesville, Indiana, “there will be significant opportunities to strengthen rural health systems by becoming an ACO or participating in a CMMI innovation model in the next 1-2 years, but providers must prepare.” Co-founder Melanie Van Winkle, CFO of Mammoth Hospital in Mammoth Lakes, California agrees, saying “this is the reason we exist, to take care of the community. The ACO helps us focus on our mission.” Steve Barnett, CEO of McKenzie Health in Sandusky, Michigan adds, “once you begin giving this type of care, you’ll never go back. We are very grateful for the support we have received from CMS, CMMI, MedPAC, and the Federal Office of Rural Health Policy. We wouldn’t be able to organize rural providers under this model without their help.”

Today, rural providers can get all of the support they need to be ready for value-based payments through the Consortium’s Practice Transformation Network, fully funded by CMMI. Medical office staff will be trained in population health management, including care coordination, quality improvement, annual wellness visits, and patient satisfaction, and can begin billing for these professional services.

Spaces are still available to join the Consortium’s Practice Transformation Network. In order to enroll in this federally-funded program that provides a population health infrastructure to rural practices at no cost, go to

Contact: Lynn Barr, Chief Transformation Officer



Read Our January 2016 Care Coordination Newsletter


It’s all about the patients. My favorite part of the month is when our monthly care coordination newsletter is published. I jump right to the back to read about the individuals whose life has been changed by their care coordinator. Care Coordinators are my heroes. In this month’s issue, we hear about how team-based approaches are breaking down barriers with patients, how care coordinators help non-adherent patients change their habits, how patients are using self-management tools to avoid hospitalizations and how care team members work to overcome financial barriers to health.

Click here to read our January 2016 Care Coordination newsletter. I hope you enjoy it.

Thank you Care Coordinators, and thank you Clinicians and hospital Administrators for supporting this important work.

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.