State Options for Rural Health Care Integration

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In this brief...

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The health care delivery system in rural America is largely fragmented. Compared to urban areas that generally contain many provider networks, large hospitals and greater access to technologies, rural areas often have a small number of independent practitioners who cover wide geographic areas, and the nearest medical specialist or hospital may be hours away. The result is a system that often is more costly and less effective at meeting the needs of rural patients.  


Because of the fractured nature of the health care delivery system coupled with the health care needs of rural residents--who may be at greater risk for multiple chronic conditions that require treatment from more than one physician or specialist--coordinating care among doctors can be difficult. It can also result in unnecessary and costly duplication of services as well as an increased risk of medical errors. To reduce inefficiencies and improve care for rural residents, state legislatures seek innovative ways to increase access to doctors and to better coordinate care.

This brief highlights several strategies states may wish to consider to improve rural health care, including health information technologies; community health workers; integration of primary care and mental health services; medical homes; and accountable care organizations. 

Health Information Technologies (HITs)

One of the keys to improving rural health care delivery is to improve the flow of information among providers and along the continuum of care. Providers in rural areas may be spread out over great distances. Travel to and from medical appointments can be difficult for patients who need to see multiple providers, have a physical disability that makes travel difficult, or do not drive or have access to a personal vehicle. However, emerging technologies are beginning to make distance less of a barrier for patient care by allowing providers to share important patient information at the click of a button.

One of the most significant challenges facing the expansion of HITs in rural America is the lack of existing broadband Internet access. Broadband refers to technology that transmits data over the Internet at high speeds and is continuously on (opposed to dial-up technology that must be connected). Broadband is essential to the use of telehealth technology because of the large amounts of data that must be transmitted, especially for video conferencing. According to the Federal Communications Commission, more than 20 million Americans lack access to adequate broadband services; 73 percent of these Americans live in rural areas. In recent years, at least 12 state legislatures have created task forces, commissions or authorities aimed at expanding broadband access in their states.

Community Health Workers

Rural areas face significant shortages of health providers. In areas where such shortages occur, the role of community health workers is especially important.  Although use of community health workers may not be appropriate for every special population or health concern, they provide another tool for public health by connecting underserved populations with health resources that otherwise would not be available. Many states now use community health workers to educate people in their community about health care options and to help them make decisions that will improve their health. Community health workers also may help patients navigate through medical diagnosis, treatment and recovery.

In recent years, a few state legislatures have taken steps to integrate community health workers into the health care system by establishing credentialing criteria. In 2007, Minnesota authorized Medicaid reimbursement for their services, thus expanding access to a broader range of services in underserved communities.

Integration of Primary and Mental Health Care Services

Many rural residents who have physical health problems also have serious mental health issues, which can have further adverse effects on their physical well-being. Mental health services tend to be scarce in rural areas. In addition, rural residents may not seek treatment on their own because of long distances to providers. Studies also show that a social stigma is often associated with seeking mental health treatment. By integrating mental health services into the primary care setting, states can increase access for rural populations and also reduce the stigma associated with seeking mental health treatment.

To help integrate these services, states will need to address the shortages of qualified mental health practitioners in rural areas. Many states use the same strategies as those for primary care shortages— through programs to recruit, train and incentivize more practitioners and increasing their telehealth capabilities.

Medical Homes

Medical homes, designed around a patient's needs, aim to improve coordination and quality of care. In addition, such improvements may help control the rising costs of health care for both individuals and other payers such as Medicaid and private insurers. In a medical home, each patient has a personal physician who is responsible for coordinating and providing or arranging all their care. Patients not only have increased access to their physician or practice, but also are more involved in health-related decisions. Patient care is coordinated across settings and practitioners (e.g., specialists, mental health professionals, nutritionists, hospitals, home health agencies, nursing homes) by a physician-led team of health care professionals. Finally, physicians receive a care coordination fee in addition to their regular office visit fee. They also may receive bonus payments for meeting or exceeding specified quality and efficiency targets. 

Although the medical home model has gained considerable support in recent years, a number of challenges remain in establishing widespread adoption in rural America. Finding enough medical practitioners to build the “teams” needed to staff this type of practice, for instance, may be difficult in an area where there may be only one medical practitioner. Finding enough patients to make it financially viable to establish a medical home also presents a challenge. Despite these challenges, states continue to examine this model; to date, at least 29 state legislatures have enacted medical home legislation.

Accountable Care Organizations (ACOs)

The success in recent years of certain provider-led accountable care organizations (ACOs) in controlling costs and improving health status has prompted policymakers to consider the ACO model as a possible replacement for the current fee-for-service model.  In an ACO, health care payers such as Medicaid, Medicare and private insurers contract with provider-led entities or provider networks to oversee all aspects of care for a specific population. Providers share costs as a collective unit and typically are paid based upon the size of the population or upon pre-determined benchmarks for individual patients. The providers assume financial risk; therefore they have an incentive to better coordinate care, control costs and improve results.

The ACO model remains largely untested, however, Colorado presents recent example of the move to adopt ACOs. It has taken steps to implement an accountable care collaborative (ACC) within its Medicaid program. Clients enrolled in the ACC receive services using the fee-for-service model, but also belong to a Regional Care Collaborative Organization that provides care coordination among providers and other community and government services. Although the program does not exactly fit the description of a traditional ACO, it is being implemented statewide. Representatives of Colorado’s Department of Health Care Policy and Financing anticipate that the new model will improve care and lower costs.


With a major expansion of Medicaid on the horizon in 2014 and health care costs that continue to outpace inflation and wages, states will continue to seek health care solutions that contain costs, create efficiencies and improve the quality of care. Integration will likely be an important component of achieving these goals. However, no single model of integration will work for all states. Integrated health care delivery systems can take many forms and will likely vary from state to state, and even from region to region within states.  States ultimately will select the best model of integration that will meet the health care needs of their rural populations.