How Can Rural Health Be Included in the Measurement Mix?

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A Rural Health Committee convened by the National Quality Forum recommended that rural providers should not just be included in quality care programs, they should be required to participate.

Life for a rural health provider can mean specializing in whatever comes through the door. The number of cases may be small, and often, no two are alike. A rural physician may be hours from a major academic center that takes on complex matters, which means long trips for patients and families.

It’s little wonder, then, that CMS excludes rural health providers from many of its quality improvement measures—it might be impossible to collect meaningful data, or unfair to judge these doctors and hospitals against standards that simply don’t match the setting.

However, as a recent report from the National Quality Forum (NQF) found, excluding rural providers means they miss out on incentives tied to performance—and patients lack information on who’s doing the best job.

The multistakeholder Rural Health Committee, convened by NQF, said the time has come to create standards with rural care in mind, and to bring these providers in to the measurement fold. HHS Secretary Sylvia Mathews Burwell has said 30% of Medicare reimbursements should be tied to value-based payment models in 2016, with the goal rising to 50% by 2018. The passage of MACRA—the Medicare Access and CHIP Reauthorization Act—makes this task urgent, since CMS reimbursement will increasingly shift to performance-based models. It is not clear how rural providers will be affected by the payment choices spelled out in the law.


Thus, not only did the Rural Health Committee call for finding ways for rural providers to take part in quality measures; it said participation should be mandatory. However, the committee’s report said this won’t happen overnight, and it should be phased in over a 2-4 year period.

“Quality improvement is important in all care settings and for all patients,” said Marcia Wilson, NQF’s senior vice president for quality measurement. “The Rural Health Committee’s recommendations to the Centers for Medicare and Medicaid are an important first step toward ensuring better quality of care for rural Americans.”

The first step, the report says, is coming up with measures that make sense for rural doctors and hospitals. The key challenge will be figuring out how to deal with low patient volumes, which the report says, “may be particularly relevant for certain condition-specific measures and/or providers in more isolated areas.”

Some providers may not offer all services—not every rural hospital performs surgery, for example—and a suite of rural-specific measures will have to take this into account. One concept calls for rural providers to use a core set of measures and select from a menu of optional ones that reflect what they do.

Measures would also have to take into account the small size of rural practices, the geographic isolation that can affect care, and the socioeconomic status of many patients—they are often poor and have less education. The report also said any measurement system must accommodate practices that may be less equipped with health information technology.

To get started, NQF calls HHS to fund a working group known as a Measure Applications Partnership, which would advise CMS on how to create measures that make sense for rural providers.

The report says pay-for-performance programs should be based on the following:

· Providers should receive incentives for meeting benchmarks or showing improvement, but should not have to pay penalties.

· Rural providers should be allowed for form groups for incentive programs.

· HHS should fund research on how rural “peer groups” could be defined for incentive purposes.

The report calls for work to begin immediately measure development and peer group research. Payment programs that offer incentives to rural providers could be up and running in 3 years.