Miller Highlights Challenges of Value-Based Care Models for Rural Health Care Providers in Ways and Means Subcommittee Hearing
Washington, D.C. – Yesterday, Congresswoman Carol Miller (R-WV) participated in a Ways and Means Health Subcommittee Hearing on the challenges and disadvantages that rural health care providers face when trying to participate in value-based care models and where improvements can be made.
Congresswoman Miller commended Dr. Sarah Chouinard, the Chief Medical Officer of Main Street Health, for her experience in the medical field and her devoted service to patients in West Virginia communities.
“[Dr. Chouinard is] a very special woman who grew up in Huntington, West Virginia. She was schooled there and [received medical training at Marshall University Joan C. Edwards School of Medicine] and practiced [medicine] in West Virginia for such a long time. She’s been a tireless advocate for the people in West Virginia and has [served as the Medical Director] for West Virginia’s Public Employees Insurance Agency (PEIA). She served as the Chief Medical Officer at the state’s second largest Federally Qualified Health Center. In that role she oversaw clinics across the central part of the state that is so mountainous,” said Congresswoman Miller.
Congresswoman Miller asked Dr. Chouinard to explain why rural providers partake less in Medicare’s value-based payment systems compared to non-rural providers.
“I have worked endlessly on rural health care because it can take you five hours to get to the hospital if that’s where your physician is. I’ve dedicated my time on the Health Subcommittee to help rural West Virginians and rural patients all over the country. People who live in urban areas don’t really comprehend the difference. Unfortunately, with Medicare’s value-based care models, we have seen multiple instances of rural providers being left behind and unable to participate. According to a 2021 report from the Government Accountability Office, rural providers participate in value-based care programs at lower rates than non-rural providers. Dr. Chouinard, in your opinion, what are some of the primary factors preventing our rural physicians from participating in value-based payment systems?” asked Congresswoman Miller.
“Administrative burden comes to the top of the pile. When you’re in small practices it becomes very difficult to dedicate a team to be able to understand what the opportunity is, and then the tracking that goes along with it, the reporting that has to go along with it. At Main Street, what we’re trying to do is take some of that burden off so that rural clinicians have a better glide path to participate. Primary Care Associations are another great stopping place for people to find information and really be able to figure out how to participate. I think on top of that, we’re just so busy, the demand for care is so high that in order to make that change, there are a lot of technology tools that we need to use. One of my fears is that we lose rural clinicians because it’s just too darn hard. If we can support them in those ways, I think that’s really the most important thing we can be thinking about right now,” responded Dr. Chouinard.
Congresswoman Miller explained how some value-based care models like the Centers for Medicare & Medicaid Innovation’s (CMMI) Emergency Triage, Treat, and Transport (ET3) model do not adequately consider rural realities when creating participation guidelines. Congresswoman Miller then asked Dr. Chouinard how CMMI can improve their models so that rural providers can participate.
"One particular example of a value-based care model that failed to adequately consider rural providers was the Centers for Medicare & Medicaid Innovation’s (CMMI) Emergency Triage, Treat, and Transport or ‘ET3’ model. The ET3 model was launched as a voluntary, five-year payment model to provide greater flexibility for Emergency Medical Services (EMS) providers following a 911 call. [EMS] providers, including those in the state of West Virginia, were thrilled about the chance to treat certain conditions at the scene of a 911 call or transport patients to alternative sites of care, outside of the typical emergency room transport. Many rural providers were discouraged, however, to learn that CMMI did not adequately consider that not all rural communities have an alternate site of care within their model regions, which made them unable to participate in the model.
I, along with the rest of the West Virginia delegation, sent a letter to the Centers for Medicare & Medicaid Services (CMS) Administrator last year highlighting these issues and asking for the agency to consider allowing West Virginia to advance a statewide demonstration of a treat in place model since the state was not able to participate in the ET3 model. Not only did CMS deny the state’s request, but it also decided to end the ET3 model two years early rather than remedy the issues that prevented EMS providers from participating in the first place.
Dr. Chouinard, in your opinion, how can CMMI do a better job of integrating small, rural, and independent providers into models? What factors of rural care delivery does CMS not seem to adequately consider when creating these models?” asked Congresswoman Miller.
“One of the things I think is problematic are volume thresholds. In the example that you gave, you had to have ‘X’ numbers of transports in order to participate. The only county in West Virginia who met that threshold was Kanawha County. Having served in a rural emergency room, lots of patients come in who did not need to be in the emergency room. But again by law, there was really no choice. The other thing that contributes to a model like that is social isolation and loneliness. Lots of patients who are anxious and lonely end up calling EMS as a result, thinking they have a heart attack and get transferred. Thinking about programs that would engage rural seniors to be able to have rural seniors have extra support, we mentioned these phone calls in between visits, checking on patients making sure we’re getting ahead of things in the vein of prevention, ensuring that if a congestive heart failure patient has swollen ankles or they’re short of breath that we’re getting ahead of that and bringing them into the office. Your suggestion that we think about the unique scenarios, problems, the geographic distance, and just the volume of people in rural communities should be a thrust of design principles in future models,” responded Dr. Chouinard.
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