October 5, 2023

The Honorable Jason Smith
House Ways and Means Committee
1139 Longworth House Office Building
Washington, DC 20515
Submitted to: WMAccessRFI@mail.house.gov

Dear Chairman Smith,

On behalf of Accountable for Health, we appreciate the opportunity to provide feedback on the request for information regarding efforts to reshape our nation’s health system and bring new access to care in rural and underserved areas. Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to support policymakers to advance the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.

The Committee is requesting comments on policies to advance innovative care models and technology, especially those that improve access to care in rural and underserved areas. Rural residents face unique challenges to accessing care. As Congress considers approaches to advancing health care for rural communities, it should build on successful accountable care initiatives that have demonstrated results for expanding access, coordinating care, and improving health outcomes.

Successful Adoption of Accountable Care in Rural Communities

Recent demonstration projects have begun to shed light on the types of accountable care delivery that is effective for rural and underserved communities. Specifically, these models have shown that costs can be lowered or remain neutral and quality, access and care coordination can be improved for these populations.

The ACO Investment Model

The Centers for Medicare & Medicaid Services (CMS) Accountable Care Organization Investment Model (AIM) was an initiative designed for organizations participating in the Medicare Shared Savings Program (MSSP) with a particular focus on attracting rural entities to the model. AIM provided pre-paid shared savings and an up-front payments based on the size of the ACO (number of beneficiaries), providing the up-front investment dollars for rural and underserved areas to participate in ACOs.

The model consisted of 45 participating ACOs, serving beneficiaries across 38 states serving a total of 487,000 beneficiaries nationwide. 27 of the ACOs reported having a critical access hospital or inpatient hospital with fewer than 100 beds as part of their ACO. Of the 45 participants, 36 had at least 65 percent of their delivery sites in rural areas.

AIM ACOs were successful in reducing total Medicare spending and utilization without decreasing the quality of care they provided. AIM generated net savings to Medicare and maintained high quality care during each of three performance years.1 AIM ACOs were located in more underserved areas and more rural areas as compared to ACOs in the Medicare Shared Savings Program, a key goal of the program. By providing access to capital needed to build infrastructure for population care management, AIM funds created access to that necessary cash flow for investment.2

The Pennsylvania Rural Health Model

The Pennsylvania Rural Health Model (PARHM) seeks to test whether delivery transformation in conjunction with hospital global budgets increase rural Pennsylvanians’ access to high quality care and improve their health, while also reducing the growth of hospital expenditures across payers. The model pays participating hospitals a fixed amount up front, regardless of patient volume, empowering these hospitals to invest in high quality care that addresses the specific needs of the communities they serve. This model is a multi-payer model, including Medicare, Medicaid, and commercial plans. The state has committed to attaining broad participation from payers and rural hospitals to help transform care and improve quality.

Key components of the model are (1) hospital global budgets – an all-payer global budget set for each hospital based on historical revenue from all participating payers; and (2) hospital care delivery transformation – deliberate action to redesign care delivery. Under the model, the state agrees to financial targets, participation targets, and population health outcomes, access and quality targets. The model began in 2019. Although the pandemic complicated model implementation, it also underscored the need to move away from fee-for-service payments reliant on the volume of services provided. Evaluation reports from the model show promising indications that the model has encouraged community partnerships, encouraged hiring of dedicated care coordination staff to facilitate care transformation, and addressing health disparities and costs through robust chronic disease management and improved care coordination.3

Policies to Accelerate Adoption of Accountable Care in Rural Communities

Based on the lessons learned from previous rural models, we recommend the committee consider the following policy areas to improve access and care coordination in rural and underserved communities:

Increasing Accountable Care in Rural and Underserved Areas

Effective accountable care models can expand access, coordinate care, improve health outcomes and lower cost, including in rural areas. As the models above demonstrate, there has been some success in designing effective accountable care delivery for rural and underserved areas. However, more can be done to accelerate this transformation and it requires taking into account the specific needs of rural providers. In particular, moving away from fee-for-service toward pre-payment models that create upfront cash flow to invest in population heath infrastructure are critical to this transformation.

Leveraging Care Teams

Effective accountable care in rural and underserved communities relies on deploying care teams that can effectively provide care to populations. This includes leveraging pharmacists, community health workers, and other professionals to provide care and expand access to services.

In many accountable care models, patient attribution (how the patient is aligned to the accountable care entity or included in the entity’s financial accountability) is determined based on primary care physician utilization. In rural and underserved communities, care may more frequently be provided by an advanced practice provider, therefore limiting beneficiary attribution. We recommend creating attribution approaches that would include advanced practice providers, thereby expanding accountability for outcomes and cost to a broader set of patients.

Encouraging Coordination with Community-Based Organizations

The change in accountability for population health often includes partnerships with community-based organizations to address social need. This could include nutrition support, leveraging community-based organizations that assist with housing, and connections to other social support organizations in the individual’s community. Accountable care delivery should be empowered to create these collaborations and connections across communities. Pre-paid models, like global budgets, population-based payments, and pre-payment of shared savings, facilitate these collaborations leading to better health outcomes for communities.

Telehealth, including Audio-Only Visits

During the COVID-19 public health emergency, Medicare telehealth flexibilities were in place and Congress extended many of these flexibilities through the end of 2024. Retaining these flexibilities for rural communities, particularly those engaged in accountable care delivery, is essential to patient access. We also encourage Congress to continue audio-only telehealth, particularly for rural communities where broadband access challenges persist. Retaining audio-only leaves the option open for practitioners to decide that it is clinically appropriate to use technology for beneficiaries who not otherwise be able to access care.

Medicare Access and CHIP Reauthorization Act (MACRA) 2.0

At the end of this year, incentives to participate in advanced alternative payment models (APMs) will expire absent congressional action. We urge Congress to reinstate and extend the 5% bonus for advanced APMs to maintain momentum toward accountable care.

As the committee considers longer term MACRA reforms, we believe there may be specific opportunities to encourage rural provider participation in accountable care models. Some rural providers have been carved out or exempted from the quality payment program, meaning they cannot qualify for incentives for participating in two-sided risk models (those where providers are accountable for cost and quality, including repaying shared losses). Creating eligibility for these participants, and particularly for those who have not participated previously, may expand participation in accountable care.


We appreciate the opportunity to weigh in on this important topic. If you have questions, please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org.


Mara McDermott signature

Mara McDermott
Accountable for Health

1ACO Investment Model (AIM): Final Evaluation of Three AIM Performance Years, CMS, available at https://www.cms.gov/priorities/innovation/data-and-reports/2020/aim-fg-finalannrpt (accessed October 3, 2023). 

2 Evaluation of the Accountable Care Organization Investment Model, ABT Associates (Sept. 2020) available at https://www.cms.gov/priorities/innovation/data-and-reports/2020/aim-final-annrpt (accessed October 3, 2023). 

3 Pennsylvania Rural Health Model (PARHM): Evaluation of Performance Years 1-2 (2019-2020), available at https://www.cms.gov/priorities/innovation/data-and-reports/2022/parhm-ar2-aag (accessed October 3, 2023).  


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