CMS seeks to advance rural, tribal, and geographically isolated community health

By: CMS Office of Minority Health Director LaShawn McIver, MD, MPH | 11/16/22

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Throughout the month of November, the Centers for Medicare and Medicaid Services (CMS) Office of Minority Health is recognizing National Rural Health Day by highlighting the resource that we’re developing to help meet the needs of Americans in rural, tribal, frontier, and geographically isolated territories.

Nearly 61 million Americans live in rural, tribal, geographically isolated areas, as well as U.S. territories that face similar but locally unique challenges regarding time and distance to health care facilities, health professional shortages, and other barriers. That’s why CMS is working to advance health equity across the nation’s health system to enable people living and working in rural, tribal, and geographically isolated communities to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.
 
To ensure CMS’ approach is responsive to the unique needs of these communities across Medicare, Marketplace, Medicaid, and the Children’s Health Insurance Program (CHIP), CMS engaged with individuals, organizations, and government entities across the nation with experience receiving health care or supporting health care service delivery in these communities. These individuals and organizations helped shape the CMS Framework for Advancing Health Care in Rural, Tribal, and Geographically Isolated Communities (referred to as the Rural, Tribal, and Geographic Framework), which focuses on six priorities over the next five years and updates existing efforts to include people living in rural areas, Tribal nations, and those in geographically isolated communities. Throughout this blog and the framework, “rural” refers to the community-informed geographic lens that encompasses Tribal nations and geographically isolated communities.
 
Click here to review the framework.
 
CMS sought input through listening sessions
In 2022, CMS held a series of listening sessions and engagement opportunities around the previous CMS Rural Health Strategy that included experts, people with lived experiences, community organizations, and rural health providers. These stakeholders provided feedback concerning areas that are working well, gaps the framework should address, and actions needed to improve the health and well-being of people living in rural areas, Tribal nations, and geographically isolated communities. The recently released Rural, Tribal, and Geographic Framework reflects the input CMS heard from an audience of more than 1,000 individuals across several public listening sessions.
 
One of the key advancements of the Rural, Tribal, and Geographic Framework is to be inclusive of rural communities as well as Tribal nations and geographically isolated areas. This supports CMS in focusing its health equity work on the unique needs of people living in rural, tribal, and geographically isolated areas, as well as the U.S. territories and frontier communities.
 
CMS builds on health equity framework
The Rural, Tribal, and Geographic Framework also builds on the CMS Framework for Health Equity 2022 – 2032 to continue CMS’ cross-cutting efforts to expand access to quality, affordable health coverage, advance health equity, and improve health outcomes for all Americans. The Rural, Tribal, and Geographic Framework consists of six priority areas designed to help guide CMS’ work in rural, tribal, and geographically isolated communities and ensure health care needs and disparities are considered as policies, programs, and initiatives are developed.

• Priority 1: Apply a community-informed geographic lens to CMS programs and policies

CMS recognizes the importance of engaging with individuals that have experience receiving or supporting the delivery of health care services in rural areas as well as Tribal nations and geographically isolated communities. Through listening sessions, town halls, tribal consultations, open door forums, and other events, we will continue to gather ongoing perspectives and regular feedback to inform new and existing CMS programs and policies.

• Priority 2: Increase collection and use of standardized data to improve health care for rural, tribal, and geographically isolated communities

Despite the importance of increasing the collection of standardized data, many rural providers lack the resources and infrastructure necessary for data collection and reporting, with these providers also highlighting the importance of CMS sharing its own data. CMS continues to publish several datasets and collaborates with the HHS Office of the National Coordinator for Health Information Technology to advance interoperability through use of the United States Core Data for Interoperability (USCDI) standard and the USCDI+ Initiative to make health care data flow more freely and securely among payers, providers, and individuals. This will facilitate better collaboration and care coordination among health care organizations to help address unmet social needs in rural communities.

CMS also recently released a blog that discusses the current state of health equity data collection and consolidation across CMS programs, including issues and challenges. As the largest payer of health care in the US, CMS can set the bar for meaningful health data across the health care industry. The blog details progress that has been made to date in improving CMS data completeness, quality, and alignment to standard and defines CMS’ future actions to continue the improvement of health equity data and achieve a vision of health equity.

• Priority 3: Strengthen and support health care professionals in rural, tribal, and geographically isolated communities

Strengthening the health workforce in these areas remains imperative, with providers and listening session participants detailing the importance of improving recruitment and retention of health care providers and allied health professionals; strengthening provider capabilities; and reducing administrative and financial burden for health care workers. As recent examples, CMS released two Medicare payment rules that include policies to support providers in rural areas. First, CMS has finalized new advance investment payments for certain accountable care organizations (ACOs) in the Medicare Shared Savings Program. These payments to ACOs are weighted to increase for ACOs serving a higher proportion of underserved beneficiaries, which may include those in rural areas and could be used to support infrastructure investments, provider staffing, and services addressing social needs.

In addition, effective Jan. 1, critical access hospitals and small rural hospitals will be able to convert their provider type to a rural emergency hospital (REH), which may be a more sustainable option for rural hospitals facing closure and supports access to care in rural and underserved communities. Conversion to an REH allows also for the provision of emergency department services, observation care, and additional specified outpatient medical and health services in rural areas.

• Priority 4: Optimize medical and communication technology for rural, tribal, and geographically isolated communities

As reliance on technology – including telehealth, patient portals and other medical technology, and communication technology – continues to grow, CMS acknowledges that rural providers and community organizations in underserved and technology-under resourced areas must not be left behind. As CMS continues to examine lessons learned from the COVID-19 pandemic, CMS has extended certain temporary flexibilities for telehealth services, including mental and behavioral health care services and treatment of substance use disorders. CMS is supporting efforts of federal agencies to address barriers to technology use and facilitate broader uptake of these technologies by building awareness of programs such as the Federal Communication Commission’s Affordable Connectivity Program.

• Priority 5: Expand access to comprehensive health care coverage, benefits, and services and supports for individuals in rural, tribal, and geographically isolated communities

CMS recognizes the potential connection between a lack of health coverage and health outcomes contributing to disparities. As such, we will work to ensure that individuals in rural areas can access necessary covered support and services. For example, CMS continues to promote state adoption of various Medicaid and CHIP initiatives to expand coverage, including the opportunity for states to extend Medicaid and CHIP postpartum coverage to 12 months postpartum.

• Priority 6: Drive innovation and value-based care in rural, tribal, and geographically isolated communities

Rural providers have experienced barriers to participating in value-based programs and models due to low case volumes, which do not always allow them to accurately report on quality measures. To help address this issue, CMS is examining Innovation Center participant selection criteria and processes to address barriers to the inclusion of safety net providers serving historically underserved and under resourced communities. In addition, CMS will work with federal, state, local, tribal, and territorial entities to prepare for, mitigate, and overcome challenges related to natural and human-made disasters so health and health care disparities for rural, tribal, and geographically isolated communities are not created or worsened. The preparedness and response toolkit for tate Medicaid and CHIP agencies in the event of a public health emergency or disaster includes strategies available to support Medicaid and CHIP operations and beneficiaries in the event of public health emergencies, disasters, or other emergencies.
 
Through the priority areas outlined in the CMS Framework for Advancing Health Care in Rural, Tribal, and Geographically Isolated Communities, CMS continues to demonstrate its commitment to enhancing access to high-quality, equitable care.
 
Learn more by visiting CMS’ rural health portal and sign up for CMS’ rural health listserv to receive the latest updates.