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Shortening the Distance: Managing Care and the Social Determinants of Health in Rural America

March 23, 2022

Challenges in areas ranging from education to the environment, gender to governance, health to housing don’t exist in a vacuum. Each month, Abt experts from two disciplines explore ideas for tackling these challenges in our monthly podcast, The Intersect. Sign up for monthly e-mail notifications here. Catch up with previous episodes here.

People in rural areas tend to suffer disproportionately from chronic health challenges while struggling to access the medical support they need. Can we provide those services and support local health providers while managing costs? Dr. Jean O’Connor and Dr. Matt Trombley share their thoughts on this episode of The Intersect.

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Read the Transcript

Eric Tischler: Hi, and welcome to The Intersect. I'm Eric Tischler. Abt Associates tackles complex challenges around the world, ranging from improving health and education to assessing the impact of environmental changes. For any given problem, we bring multiple perspectives to the table. We thought it would be enlightening and maybe even fun to pair up colleagues from different disciplines so they can share their ideas and perhaps spark new thinking about how we solve these challenges. Today I'm joined by two of those colleagues, Dr. Jean O'Connor and Dr. Matt Trombley.

Jean has more than two decades of experience working at the federal and state level to address social determinants of health and build equitable, resilient, and healthy communities. Matt has over 10 years of experience in applied health economics and health policy evaluation, and his primary research currently encompasses value-based payment designs, such as bundled payments and accountable care organizations or ACOs.


Jean O'Connor: Thank you.

Matt Trombley: Thanks, Eric. Pleasure to be here.

Eric: Jean, let's start with you. You recently wrote a great blog on rural areas and the social determinants of health. What are some of the health challenges that you see as particularly distinct in rural areas?

Jean: Yeah. Rural areas really face a significant health burden. People who live in rural areas, especially older adults, are more likely to face higher rates of obesity, food insecurity, diabetes, cardiovascular disease, stroke, and even injury. Things like motor vehicle-related crashes, rates of poor outcomes and death, even, from some of those kinds of things are higher as well.

Eric: Matt, why don't you tell us a little about ACOs, which are intended to help rural areas?

Matt: Sure. An ACO stands for an accountable care organization. And as the name suggests, this is something that brings together different groups of providers to be accountable for the entirety of beneficiaries patients’ care. So essentially, under a standard fee for service payment, each different service that a beneficiary receives, going to the doctor, visiting the ER, will all come with a separate bill, whereas under the accountable care system, each beneficiary, their total cost care over the course of a year is attributable to the organization. And so these organizations band together to coordinate care across the different types of providers, and then hopefully provide care more efficiently with higher quality, which has the added benefit of helping to hopefully curb costs.

Eric: Right. And Matt, you've evaluated ACOs. What were your findings?

Matt: Right. The ACO investment model in particular was a CMS model that Abt Associates evaluated. And we found ultimately that the ACO investment model reduced net Medicare spending by about $380 million over the course of three years. This was primarily achieved by keeping people out of the hospital, out of other types of institutional care. And we saw this without any adverse effects on patient-reported measures of quality, as well as other more claims-based measures of quality. So it seems that CMS was able to reduce spending overall, while helping to keep people out of the hospital and not otherwise having adverse impacts on their care.

Eric: Great. So AIM is intended to help ACOs with challenges they might be facing. Jean, you want to tell us what some of those challenges are?

Jean: Well, in rural areas, providers really are going to face a number of challenges in participating in an ACO. First, their patients are pretty widely dispersed, and the providers themselves are pretty widely dispersed. In an urban area, you may have a group of providers affiliated with a health system who are all participating. Their patients are in a small geographic area. They're able to manage them physically and through things like their data systems. In a rural area, you may have a large group of otherwise unaffiliated primary care providers, an unaffiliated hospital, other unaffiliated specialists, all in an ACO.

And they may be spread out over, in some cases, a dozen counties or more in some large rural states. And they won't share the same electronic health record system necessarily, so they're going to be really highly dependent on things like the state's health information exchange and using that to be able to share information and data about patients in a timely way. They're going to be really dependent on informal networks of communication with those other providers. And all of those things can really make achieving the intended outcome of an ACO more challenging, particularly when you're trying to talk about achieving shared savings and you're working with someone several counties over that you've maybe never sent a patient to.

And also, if you're a primary care provider in a rural area, you may not have a large staff, and you may only see one or two of a particular kind of a serious chronic condition or someone with multiple chronic conditions. And managing those patients in that kind of a setting can be really challenging. It's really different from being in an area where you might see a high volume of the same number of patients with the same kinds of conditions. So I think we have to keep all those things in mind when we think about the implementation of ACOs in rural areas.

Matt: Right. So the ACO investment model was designed with some of these challenges in mind, primarily those financial barriers, things that can be solved with additional funding. So you mentioned the need for electronic health record systems that can communicate across providers, perhaps additional--not only hardware and software--but the IT staff to maintain them, hiring new staff--such as care coordinators, or new clinical professionals who can triage patients during off hours, or these types of capabilities that may sort of come naturally at scale to large urban providers. Those types of investments require financial investments that typically are unavailable to small rural providers. And so the ACO investment model tried to tackle this by providing not only a set amount of upfront funding for these accountable care organizations, but also two years of ongoing payments at a per beneficiary level, so that the larger the organization was, the more support they got to try to scale up in a way that could meet the populations they were serving.

Jean: And I really like what you said about care coordinators because one of the things we haven't talked too much about yet, but that is important in rural areas, and it's important in urban areas too, is this need for not just care coordination, but also support for patients in achieving their health goals and identification of things that might be getting in the way of them be being able to control their diabetes or control their hypertension. Do they have what they need at home to be able to do that? Are they able to eat well enough? Do they know where their meals are coming from, and can they get fresh fruits and vegetables and those kinds of things? Those are challenges everywhere in this country for people. But in particular, in rural areas, there may be a greater opportunity even to try to help connect people to existing services or solve challenges in their communities that might be preventing them from being able to do the things that their physician is recommending in order to control their chronic condition.

Eric: So with that in mind, Jean, what do ACOs and the AIM model mean to you in terms of people living in rural areas?

Jean: Well, anytime you can keep people out of the hospital or help keep them well, that's a good thing for those individuals and for the communities and for their families. One of the things in rural communities that's really challenging is oftentimes, there's a long distance to care. You may have to travel a long way to get to your primary care provider, and particularly to get to specialty providers or acute care that you may only be able to get in the hospital. Sometimes people are traveling upwards of two to three to four hours to get to acute care facilities that can meet their needs for their specialized condition or provide that state of the art care. So really, anything we can do to try to keep people and their families from having to go through those kinds of things is really important.

Accountable care organization models have been really successful, as Matt just described, in some places. And they can really help to ensure that not only do people stay out of the hospital, but that they have a good care experience. They're getting only the care they need, not care they don't need. And they're getting it from people who understand who else they've seen and what their medical history might be. So in that regard, accountable care organizations can be a great thing for many people.

Eric: And we talked a little bit before this podcast about some concerns, both with the AIM model and rural hospitals in general, and specifically making sure they're still able to operate. Matt, you want to start first and talk about some of the challenges you found?

Matt: Right. There's always this tension between, at least in the rural context, certainly, or any sort of underserved area, between the goal of trying to provide care more efficiently, but also trying to balance access when doing so. So a lot of these rural providers, particularly hospitals, may be operating on very low margins, have very little financial bandwidth, or margin rather. And so if you're trying to deliver care more efficiently and keep people out of the hospital, you're actually reducing revenue for these critical service providers, potentially causing an existential threat for these organizations. And so being able to balance the need to keep people out of the hospital when they don't need to be there, while at the same time making sure the hospital stays in place to be able to continue providing care for those who need it.

Eric: Right. And Jean, how about you, because there's a follow on from that immediate threat to the facilities, right?

Jean: Yeah. So of course, having those facilities there is really important because a lot of times, not only are they important to providing the acute care, but they act as a center in the community. Many times you'll see primary care practices surrounding hospitals or affiliated with hospitals. And so the wellbeing of the hospital is important to the wellbeing of the community and therefore the patients and the people that are served. At the same time, there's this opportunity that comes along with this to really transition what services are being offered. More and more, we know about evidence-based interventions that, if delivered to people, can help keep them in their homes. And in some cases, those interventions are new services that hospitals and healthcare providers could be offering, but aren't currently. And so making those kinds of transitions in their practices can also have this sort of net effect of helping the community overall, both maintain its infrastructure while also transitioning to some of that more preventive care.

Eric: Let's talk a little bit more about helping facilities to stay operational. Matt, you want to talk about some of your findings in the AIM evaluation, in which you suggest there are some alternate approaches in which both facilities and CMS can benefit? And I'm thinking specifically of how you looked at downside risk.

Matt: Right. It's taken as a given by a lot of payers, particularly CMS on the Medicare side, that eventually organizations participating in these value-based payment programs are going to have to take on what's called downside risk. Currently, under upside only risk or one-sided risk, providers can share in the savings that they generate by reducing unnecessary care, but they are not on the hook for paying back CMS if costs go up. And so, eventually, the goal is frequently to move participants to that higher downside risk where they face the possibility of having to pay out money to CMS. Now, again, we talked about how, in these rural areas, a lot of providers may not have the ability to take on that kind of risk. They just don't have the financial capability to absorb a string of bad luck. And so, one thing to consider in these particular contexts is to allow providers either a longer pathway to downside risk or potentially to wave downside risk completely.

The way that our AIM evaluation informs this is we did find that when the model ended after three years, about two thirds of the participating organizations left the model. They quit participating as ACOs. But when we looked at the data, those who stayed and those who left had generated essentially equal savings for CMS on a per-beneficiary level. And that's true across all three years of the model. So it looks like the model potentially left some money on the table in terms of organizations that were generating savings under the one-sided risk choosing to leave the model when faced with downside risk. And so it opens the question of whether savings can be achieved and maintained without downside risk, at least in the rural context, and also the extent to which that may provide a better ability for sustaining the existence of these rural providers because they're not being faced with these potential negative shocks, these downside risks that could be financially ruinous for them.

Eric: Yeah, so that's an exciting question. And so, let me pivot from there to say, what next? This is actually like this nice conversation where it feels like gains are being made. What do we want to be looking at next to keep making gains and help bolster these communities?

Jean: I was just going to comment, Eric, on what you were saying about and what Matt was saying about the risks in rural communities. I think one of the things we have to recognize is that a lot of things are harder in rural communities, and there are some significant shifts happening in demographics. Younger people are moving away from rural areas and into urban areas. The economy is primarily still agriculture in most rural communities. And so when we think about what's going to make sense for healthcare providers, I think we have to keep in mind that they are absorbing an older, by and large sicker population, and they face significant challenges in retaining staff and other things that are required to keep their practices operating. So it's never been easy to work in a rural area, an under-resourced or an underserved area. But I think, particularly as we see these demographic shifts continuing, it's definitely something that might be important to bear in mind as we think about designing models that work.

Matt: One of the key design features for this upcoming CHART model, which is more focused on--not so much grouping together providers under an accountable umbrella--but an actual community led by certain organizations. And so in these cases, there is a focus in the design of the model to really drill down on some of these populations who either have multiple chronic conditions or behavioral health or substance use disorders. So really trying to drill down on these populations that can be overrepresented in the rural areas, but who have enormous healthcare needs, and frankly, can drive a lot of healthcare costs, and really trying to improve healthcare for these individuals in a way that they hope will also lead to savings down the road as well.

Eric: Well, it's great that the two of you are investigating these rural health challenges from both the community aspect and then the financial aspect in terms of health services. So I'm glad that intersect is taking place within Abt. Thank you both for joining me.

Matt: Thanks, Eric.

Jean: Thank you.

Eric: And thank you for joining us at The Intersect.

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