Clinton MacKinney, MD, MS; Fred Ullrich, BA; and Keith J. Mueller, PhD

Approximately 10 percent of primary care clinicians participate in Advanced Alternative Payment Models (A-APMs) and less than 30 percent of primary care clinicians participate in the Merit-Based Incentive Payment System. Metropolitan primary care clinicians are more likely to participate in A-APMs than non-metropolitan primary care clinicians.

Click to download a copy: Primary Care Clinician Participation in the CMS Quality Payment Program

Medicare beneficiaries may be admitted to home health following an inpatient stay (post-acute) or directly from the community (community-entry). An analysis of Medicare data for rural, fee-for-service Medicare beneficiaries who utilized home health from 2011 to 2013 found significant differences in care processes between community-entry and post-acute home health. Compared to post-acute home health episodes, community-entry home health episodes on average were longer; less likely to include physical, occupational, and speech therapy visits; more likely to include medical social work visits; and less likely to be initiated on the physician-ordered start date or within two days of referral. Results suggest community-entry and post-acute home health are serving different needs for rural Medicare beneficiaries, which provides preliminary support for distinguishing between the two types of episodes in payment policy reform.

The Office of the National Coordinator (ONC) reports that nearly all hospitals provided patients with the ability to electronically view and download their personal information in 2017.  However, Critical Access Hospitals (CAHs) and small rural hospitals were less likely than larger and urban hospitals to be able to transmit that data and to have view, download, and transmit (VDT) capabilities.  Under the Promoting Interoperability Program (PI), hospitals are required to use electronic health records technology.  Another aspect of the program is to promote patients’ ability to view and download their personal health information.  The cost of electronic health record systems and limited access to broadband are two of the barriers to electronic capabilities in rural health care settings. See the Policy Updates section below for requests for comment on recent proposals on electronic health information networks.

The Appalachian Regional Commission (ARC) is a federal agency created by Congress to partner with state and local governments and promote economic development for the region.  This month, the ARC released three separate issue briefs on health disparities in the 13 states of the region – Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia.  The briefs describe the factors unique to the region that contribute to disparities related to obesity, opioid misuse, and smoking, and provide recommendations and practical strategies for communities.

 

From the Daily Yonder…

By Tim Marema

April 18, 2019

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Rural America’s population grew by 0.1 percent from 20017 to 2018. The growth was small and clustered near metropolitan areas. But it reverses the trend of population loss that occurred from 2011 to 2016.

The size of the non-metropolitan population crept up for the second year in a row in 2018, adding about 37,000 residents to reach 46.1 million.

That’s a gain of about 0.1 percent, according to a report from demographer Kenneth M. Johnson at the University of New Hampshire’s Carsey School of Public Policy.  The rate of growth is roughly the same as the growth rate from 2016 to 2017, when non-metropolitan counties added 33,000 residents.

The overall U.S. population grew by about 0.6 percent over the last year.

While the gains for non-metropolitan America were scant, they continue to reverse the historic drop in non-metropolitan population that occurred from 2011-16.

The map shows which counties gained or lost population from 2017 to 2018. County-level data is available  a map. Or see the map in a new, full-sized window.

About half of America’s 2,000 or so non-metropolitan counties gained population, while about three quarters of metropolitan counties did.

Rural America’s net growth came from rural counties that are adjacent to metropolitan areas, Johnson said in his report. Those counties gained 46,000 residents, while non-metro counties that don’t touch a metro area lost 9,000 residents.

Johnson said non-metro counties grew from a combination of migration (more people moving into a county than leaving it) and natural increase (more births than deaths). The rate of natural increase is dwindling, Johnson said.

Growth rates in non-metropolitan American varied by region. “The fastest growing counties have recreational and scenic amenities that attract migrants including retirees from elsewhere in the United States,” according to the report. In contrast, farm counties had more people leave than move into the counties.

The Census Bureau, which released the 2018 population estimates Wednesday (April 18, 2019), noted that the South and West tended to have the fastest numerical growth in counties.

How this story defines rural: This story uses the Office of Management and Budget metropolitan statistical area system to define rural. Rural counties are defined as those that are not in a metropolitan statistical area or MSA. In this story, rural is synonymous with non-metropolitan. There are numerous ways to define rural. You can learn more (much more!) from the USDA Economic Research Research and the U.S. Census. 

The National Institutes of Health has selected four research sites for the HEALing Communities Study in states hard hit by the opioid crisis. This ambitious study aims to reduce overdose deaths by 40 percent over three years in selected communities by testing a set of proven prevention and treatment interventions.  More than $350 million will support this multi-year study.  Applications included the involvement of community resources such as police departments, faith-based organizations, and schools, with a focus on rural communities and strong partnerships with state and local governments.

Medicare Advantage Enrollment Update 2018

Onyinye Oyeka, MPH; Fred Ullrich, BA; and Keith Mueller, PhD

The RUPRI Center’s annual analysis of Medicare Advantage (MA) enrollment shows that there are 2.6 million nonmetropolitan beneficiaries (24.6 percent of eligible nonmetropolitan beneficiaries) enrolled in an MA plan. The number of nonmetropolitan beneficiaries enrolled in an MA plan increased by 9.5 percent from 2017 to 2018. Nonmetropolitan MA enrollment remains significantly lower than metropolitan enrollment (24.6 percent v. 36.4 percent), but in 2017 the nonmetropolitan rate of growth in MA plan enrollment was higher than the rate of growth in metropolitan areas (4.7 v. 2.0 percent).

Among MA plans, nonmetropolitan enrollment in private fee-for-service MA plans declined sharply between 2009 and 2018, while nonmetropolitan enrollment in health maintenance organizations (HMOs) and local preferred provider organizations (PPOs) saw significant increases.

Click to download a copy: Medicare Advantage Enrollment Update 2018

SIM Initiative Evaluation: Model Test Year Five Annual Report. In December 2018, the Center for Medicare & Medicaid Innovation released its fifth annual report on Round 1 of the CMS State Innovation Models (SIM) Initiative, which tests the ability of the governments in six states (Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont) to move providers to value-based payment. A number of these states had activities involving rural providers, including RHCs, FQHCs, and CAHs. As a key finding, states used SIM awards to provide resources to providers to enable provider participation in Medicaid alternative payment models. While most state-led models supported through SIM did not realize Medicaid savings, many results were promising considering the limited provider incentives. A 2017 guide from Rural Health Value highlights the rural focus within select SIM awards from Rounds 1 and 2.

CMS releases Care Coordination Toolkit and series of ACO Case Studies. The Centers for Medicare & Medicaid Services (CMS) has released a public Accountable Care Organization (ACO) Care Coordination Toolkit highlighting innovative strategies that ACOs and End-Stage Renal Disease Care (ESRD) Seamless Care Organizations (ESCOs) use to collaborate with beneficiaries, clinicians, and post-acute care partners to ensure high-quality, effective care is provided at the right time and in the right setting. CMS has also released seven case studies to describe innovative initiatives from ACOs and ESRD ESCOs on a variety of topics including engaging beneficiaries, coordinating care in rural settings, and promoting health literacy. Each case study includes detailed results and lessons learned.

Dying Too Soon: Disparities in Death By Rurality, Race, and Ethnicity.  A recently released brief by the Rural Health Research Gateway finds rural counties had higher rates of premature death (defined as years of potential life lost before age 75) than urban counties.  Researchers analyzed data from the 2017 County Health Rankings, and found that counties with a majority of residents identifying as non-Hispanic Black or American Indian/Alaska Native had significantly higher rates of premature death.