H Iovatios i Rural Health System Developmet Movig Rural Health Systems to Value-Based Paymet Sara Kah-Troster, MPH Adrew Cobur, PhD Rapid chages i health care paymet ad delivery systems are drivig health care providers, payers, ad other stakeholders to cosider how the curret delivery system might evolve. This series of briefs profiles iovative rural health system trasformatio models ad strategies from Maie ad other parts of the Uited States. The aim is to assist rural commuities ad regios to proactively evisio ad develop strategies for trasformig rural health i the state. I preparig these briefs we cosulted experts, iterviewed key iformats, ad reviewed the professioal ad research literature to fid robust ad iovative models ad strategies that could be replicated i rural Maie. PROMISING STRATEGIES: Accoutable Care Orgaizatios... 2 Medicaid Accoutable Commuities... 5 Additioal Fiacial Models... 6 INTRODUCTION NOVEMBER 2016 Muskie School of Public Service Maie Rural Health Research Ceter Muskie School of Public Service How we pay for health care has critical implicatios for health care quality, access to care, ad the cost of services i the health system. Curretly there is itese iterest i movig health care paymet systems away from models that create icetives for providers to provide more care (i.e. icrease volume), to oes that reward value services that are both efficiet ad high quality. The Affordable Care Act cotais may provisios desiged to implemet or test iovative, value-based Medicare ad Medicaid paymet models, icludig accoutable care/shared savigs (Accoutable Care Orgaizatio (ACO) models), budled paymets, ad health homes iitiatives. I additio, states, icludig Maie, are participatig i State Iovatios Models (SIM) grats or other iovatio models from the Ceter for Medicare & Medicaid Iovatio (CMMI) that are testig ew approaches to payig for health care services.
FIGURE 1: Medicare ACO Models MSSP: The Medicare Shared Savigs Program, established by the Affordable Care Act, rewards ACOs that lower their growth i health care costs while meetig performace stadards o quality of care ad puttig patiets first. ACOs that achieve certai fiacial ad quality bechmarks receive some of the moey that Medicare has saved o the ACOs patiet populatio. Advaced Paymet ACO: I this model, which is targeted to small ad rural providers, a subset of MSSP participats receive up-frot paymets (variable or fixed depedig o the ACO). Next Geeratio ACO Model: This is a iitiative for ACOs that are experieced i coordiatig care for populatios of patiets. It will allow these provider groups to assume higher levels of fiacial risk ad reward tha are available uder the curret Pioeer Model ad MSSP. Pioeer ACO model: This model is desiged for providers ad health systems that are very advaced with substatial care coordiatio capacity. It is o loger acceptig ew applicatios, i favor of the Next Geeratio model. For may rural health care providers, participatig i iovative paymet iitiatives ca be challegig. For example, may lack the ecessary ifrastructure, icludig havig care maagemet staff ad systems ad the ability to use their electroic health record (EHR) data to moitor the care of their patiets. I additio, may rural providers do ot meet the thresholds for participatio because of their lower patiet volume. Ad fially, may of the ew icetive-based paymet arragemets do ot work with curret Medicare ad Medicaid cost-based rural hospital ad other paymet arragemets. Notwithstadig challeges, there are a growig umber of examples of rural health care providers participatig i iovative paymet iitiatives. The followig examples of paymet iovatios i rural areas illustrate the rage of optios available to commuities ad health care providers. I geeral, these ad other examples idicate that while wholesale chages i paymet systems are challegig i rural commuities, gettig started with icremetal steps that build the capacity ad experiece of rural providers is possible ad ideed essetial. PROMISING STRATEGIES Accoutable Care Orgaizatios (ACOs) ACOs are groups of doctors, hospitals, ad other health care providers, who volutarily agree to cotract with Medicare, Medicaid, or other payers or health plas to provide efficiet, high quality care to a attributed populatio of patiets. 1 Figure 1 describes the variatios i Medicare ACO models. The paymet arragemets for each of these ACO models differs cosiderably i terms of whether ad how providers are rewarded or pealized for meetig quality ad cost targets. I geeral, rural providers ad health systems participatig i the Medicare MSSP program cotiue to be paid o a fee-for-service basis ad are limitig their fiacial risk by oly seekig shared savigs rewards. There are cosiderable barriers to rural providers participatig i ACO models. These iclude: May rural providers service delivery areas do ot meet the miimum Medicare threshold of 5,000 beeficiaries. Some may meet the threshold iitially but risk fallig below it if a provider drops out. Rural physicia practices ad hospitals have fewer resources to put toward the upfrot ivestmets i ifrastructure ad persoel eeded to effectively maage patiets care. MSSP program participats ca also participate i the ACO Ivestmet Model (AIM) which is specifically targeted to rural ad uderserved areas. I this model, ACOs are able to obtai a up-frot paymet from Medicaid reflectig their expected savigs. This ca help providers build care maagemet ad other capacity ecessary to be successful as a ACO. The fiacial overhead of ruig a ACO (for the EHR ad other reportig systems, as well as care coordiatio) may be a deterret, especially for practices with a heavier focus o primary care ad fewer specialists (where there is greater potetial for achievig savigs ad improvig quality). It may be harder to fid staff i rural areas who are qualified to fill care coordiator ad other positios that a ACO requires. Rural providers may also have a harder time complyig with the ecessary rules ad regulatios. Movig Rural Health Systems to Value-Based Paymet 2
EXAMPLES OF ACO MODELS BEACON HEALTH: A ACO i Rural Maie Beaco Health, part of Easter Maie Healthcare Systems (EMHS), is operatig at the forefrot of iovatios i value-based purchasig. Beaco Health s ACO bega as a Pioeer ACO i 2012, but is ow part of the Next Geeratio ACO Model, which allows providers to assume a greater level of risk but also greater savigs tha are possible uder the stadard MSSP. The Next Geeratio Model also moves participats toward capitated paymets (fixed mothly Medicare paymets based o the umber of beeficiaries i the ACO, regardless of whether or ot they seek care), ad cotais some Medicare beefits ehacemets, such as a waiver of the rule that requires a three day hospital stay before Medicare will cover the cost of a skilled ursig facility. Beaco Health is also part of the Ceter for Medicare & Medicaid Services AIM iitiative, which ecourages ACOs to form i rural ad uderserved areas, ad ecourages curret MSSP ACOs to trasitio to arragemets with greater fiacial risk. The Beaco Health ACO icludes Critical Access Hospitals (CAHs) affiliated with EMHS, as well as other rural hospitals. Fially, Beaco Health is a MaieCare Accoutable Commuity, although at preset oly a few etwork practices are participatig. Beaco Health s participatio i the Medicare Next Geeratio ACO ad AIM models is eablig them to ivest i the developmet of their care coordiatio ifrastructure. Nurse care coordiators are beig embedded across the Beaco Health etwork i practices (icludig practices associated with CAHs ad other rural hospitals) with the expectatio that they will help reduce readmissio rates, icrease patiet egagemet i their health, ad improve commuicatio with patiets ad practices. The iclusio of rural providers CAHs ad primary care practices i Beaco Health is part of a larger strategy of eablig these rural providers to develop capacities that will allow them to survive i the rapidly evolvig health care system. Beaco Health presidet Michael Doahue otes that CAHs are developig approaches desiged to help them keep their doors ope with icreased volume, especially i swig beds. Together with its affiliated CAHs, Beaco Health is examiig which core services are crucial to have locally, keepig patiet care i the commuity, at the CAH, ad which services are best hadled by larger facilities. Doahue ad others have suggested that allowig CAHs to have a global paymet structure from Medicare, eve if oly as a pilot program for several years, would allow them to ivest i key ifrastructure ad persoel, to help move their hospitals away from ipatietcetered care ad fee-for-service paymets. It would also give them the flexibility ad resources to forge coectios with social services, trasportatio, behavioral health, ad other local services that are part of the bigger populatio health picture i their commuities. He oted that coectios with other service providers is a essetial strategy for reducig uecessary admissios ad readmissios, ad achievig better patiet outcomes ad quality of life. As a example, he cited Blue Hill Memorial Hospital s relatioship with Healthy Peisula, a local commuity health program, which might be a model for other small rural commuities ad their CAHs. THE MAINE COMMUNITY ACO: A Statewide Rural ACO The Maie Commuity ACO (MCACO) is a partership of FQHCs i rural Maie. Established i 2012, MCACO is oe of 119 MSSP ACOs atiowide, ad the oly oe i Maie that qualified for shared savigs based o its 2015 performace o quality stadards Movig Rural Health Systems to Value-Based Paymet 3
ad pre-set fiacial bechmarks. The shared savigs amout to early a millio dollars, which will be distributed back to the participatig health ceters. I iterviews with Lisa Letoureau, the executive director of Maie Quality Couts, MCACO leadership oted that focusig o high-risk admissios, as a meas of both improvig quality ad reducig costs, is a key factor for success. 2 I particular, MCACO data suggested that two coditios, heart failure ad COPD, were associated with the greatest umber of potetially avoidable hospital admissios ad readmissios. Dedicated care coordiatio ad patiet self-maagemet educatio have cotributed to improvemets i care for these coditios. MCACO practices also leverage the Medicare Aual Welless Visit to get to kow patiets better ad to flag the oes with particularly high health care eeds ad complex illesses. MCACO has ivested i site-level cliical leadership ad committed to maitaiig a cotiuous focus o quality. The sharig of best practices across practice sites is also cited by MCACO leadership as a key strategy for patiet-focused quality efforts that lead to improved outcomes ad lower costs. THE ILLINOIS RURAL COMMUNITY CARE ORGANIZATION: A Statewide Rural ACO Illiois Rural Commuity Care Orgaizatio (IRCCO) is comprised of 25 CAHs ad their associated physicia practices ad cliics located i rural commuities across Illiois. It operates as a limited liability compay established by ICAHN, the Illiois Critical Access Hospital Network. IRCCO s participatig orgaizatios are servig 30,000 Medicare beeficiaries. Like Beaco Health, IRCCO is part of the AIM iitiative, which ecourages ACOs to form i rural ad uderserved areas, ad ecourages curret MSSP ACOs to trasitio to arragemets with greater fiacial risk. Participats i IRCCO receive pre-paymet of shared savigs i both upfrot ad ogoig per beeficiary per moth paymets. Potetial uses of AIM fudig iclude ivestmets i ifrastructure ad hirig of staff to oversee the implemetatio of care coordiatio efforts. IRCCO members are required to fiacially support the costs of orgaizig ad ruig the orgaizatio i the first two years. Added icetives for providers come from IRCCO s participatio i the Blue Cross Blue Shield of Illiois (BCBSIL) Itesive Medical Home, which is a ehaced model of primary care focusig o the high-risk chroic care beeficiaries. IRCCO is paid for urse care maagemet services ad providers are reimbursed based o the umber of BCBSIL members erolled based o claims iformatio. 3 Early efforts have focused o buildig the ifrastructure ad processes ecessary to fuctio as a ACO, icludig appreciatig the eed for culture chage i may participatig orgaizatios, ad educatio about the importace of reducig costs ad improvig outcomes. Movig forward, IRCCO will cocetrate its efforts o care coordiatio ad care trasitios, particularly for patiets with chroic illess. Four IRCCO workgroups are collaboratig to address topics such as uecessary emergecy departmet visits, hypertesio, cogestive heart failure, ad Medicare aual welless visits. IRCCO is also leveragig fuds provided by the Medicare Rural Hospital Flexibility Grat Program (the Flex Program) to establish cohorts of CAHs to develop care coordiatio processes ad stadards of practice for specified chroic diseases. Although there are still challeges to be addressed (such as improvig health iformatio techology capacity ad implemetig care coordiatio systems), IRCCO has brought rural hospitals together to begi to expad their capacity to participate i value-based paymet models. Movig Rural Health Systems to Value-Based Paymet 4
PROMISING STRATEGIES Medicaid Accoutable Commuities A Accoutable Commuity is a Medicaid ACO model adopted by states as a state Medicaid program optio. Maie s Medicaid program (MaieCare) has a Accoutable Commuities program through which it cotracts with coalitios of health care providers who, as i a ACO, ca share i savigs for their populatio. Achievig shared savigs i the Medicaid Accoutable Commuity model is cotiget o meetig quality targets. 4 There are two shared savigs/risk models that require differet levels of MaieCare erollmet (uder ad above 5,000 patiets), ad core ad optioal services that ay Accoutable Commuity must provide. The savigs are calculated as a percet of the bechmark total cost of providig care, compared to the actual cost of providig care, with the percet set by the populatio size of the Accoutable Commuity. 5 At preset, the model pays providers o a fee-for-service basis. It is a upside-oly model, with the potetial for shared savigs but o dowside fiacial risks for providers. KENNEBEC REGION HEALTH ALLIANCE: A Medicaid Accoutable Commuity Keebec Regio Health Alliace (KRHA) was formed i 1997 as a physicia-hospital orgaizatio cosistig of MaieGeeral Medical Ceter ad members of its medical staff. Keebec Couty is its primary service area, although it also has practices i six additioal couties. KRHA has participated i the MaieCare Accoutable Commuity iitiative sice its iceptio. The Accoutable Commuity started small, iitially with just the MaieGeeralowed practices, ad the expaded to ay member of the KRHA that wated to joi. There are curretly 25 practices i the Accoutable Commuity servig about 20,000 patiets. KRHA was already participatig i may care maagemet models, icludig patiet cetered medical homes/health homes, behavioral health homes, ad care maagemet teams, ad the opportuity to be a Accoutable Commuity offered a way to alig those multiple iitiatives to potetially reduce MaieCare utilizatio at MaieGeeral. Dr. Barbara Crowley, executive vice presidet at MaieGeeral ad the presidet of KRHA, oted that, o average, 22 out of the 192 beds at MaieGeeral are occupied by a Medicaid patiet (ot Medicare or private pay), ad that reducig that umber, eve by oe, through Accoutable Commuities ad other care coordiatio iitiatives, would have a sigificat impact o the bottom lie. KRHA s Accoutable Commuity has bee i place for three years. It has focused its care coordiatio services o childre with multiple behavioral ad physical health eeds. The iitiative has paid particular attetio to helpig behavioral health providers follow evidecebased practices. They are lookig to develop targeted case maagemet for the childre i the Accoutable Commuity, with care coordiatio ad improved commuicatio betwee differet providers ad agecies. Greater fiacial rewards ad challeges will come whe the Accoutable Commuity icreases its attetio to agig, blid, ad disabled adults, whose care carries the largest fiacial burde i Medicaid. I the first performace year, the Accoutable Commuity is close to achievig shared savigs paymets, less tha 0.2% away from the target for total cost of care. Movig Rural Health Systems to Value-Based Paymet 5
PROMISING STRATEGIES Additioal Fiacial Models CARY MEDICAL CENTER AND PINES HEALTH SYSTEM: Sharig Fiacial Resources ad Specialists Cary Medical Ceter (Cary), a 65-bed acute care hospital i Caribou, Maie, ad Pies Health Services (Pies), a commuity-based, multi-specialty physicia practice ad Federally Qualified Health Ceter (FQHC) servig Aroostook Couty, have a log-stadig, mutually beeficial relatioship i which they share resources to esure that the commuity ad the hospital have adequate primary care ad specialty staff to maitai a sustaiable health system. Accordig to Pies CEO James Davis, each orgaizatio is made stroger by servig the commuity together. Pies was fouded by Cary 31 years ago, i a era whe hospitals were lookig to add oacute care etities to offer a wider rage of services. Over time, Pies has become a large multi-specialty physicia group with more tha 40 providers divided about evely betwee primary care ad specialists. Although it is uusual for a FQHC to have specialists, their presece (techically outside the FQHC grat) allows patiets to access eeded services quickly withi the same system. This arragemet fuctios well due to the strog, ogoig relatioship with Cary, which maitais a agreemet to exchage services ad staff. Pies status as a FQHC allows for better reimbursemet for publicly isured ad uisured cliets, ad has allowed Pies to be less fiacially depedet o Cary. Cary ad Pies collaborate to create workable budgets for Pies. Pies providers geerate about 80-85% of Cary s reveues. I retur, Cary provides Pies $2 millio aually i commuity beefit paymets to support primary care, ad a additioal $5 millio that eables Pies to recruit specialists. I rural Maie, it would be very difficult for a specialist to be successful with a purely office-based practice, but the relatioship with Cary offers specialists access to a hospital-based practice as well. Pies curretly employs specialists i areas such as ophthalmology, urology, gyecology, ad geeral surgical services. Ogoig fiacial pressure o hospitals to improve quality ad reduce costs creates challeges ad opportuities i this arragemet. Capitalizig o its primary care resources, Pies is workig closely with the hospital to decrease emergecy room use; Davis estimates that a third to a half of all emergecy departmet visits could be dealt with i primary care settigs, where patiets would get more comprehesive, ogoig care at a lower cost to the system. The hospital, i tur, works with MaieCare patiets to eroll them i Pies or other practices so they have a medical home ad cotiuity of care. SUMMIT PACIFIC MEDICAL CENTER, WASHINGTON STATE: Takig the First Steps Summit Pacific Medical Ceter (SPMC) is a idepedet, public hospital district CAH i Elma, Washigto, servig about 25,000 people i the wester part of the state. Faced with serious fiacial problems several years ago, SPMC re-focused its attetio o growig its primary care, emergecy care, ad other outpatiet services, de-emphasizig its i-patiet services. At preset, about 90 percet of SPMC s reveue comes from outpatiet services. 6 Although they are licesed for 24 ipatiet beds, SPMC CEO Reee Jese otes that they oly staff 10 beds. Istead, they have grow their primary care cliics from oe to three, with a ew welless ceter curretly beig built to complimet their curret hospital facility which opeed i 2013. SPMC s focus o primary care ad other prevetio services comes Movig Rural Health Systems to Value-Based Paymet 6
from their assessmet that the commuity eeded a greater emphasis o prevetig chroic diseases. Their welless focus also icludes itegratio of behavioral health services with primary care, ad targeted commuity health improvemet iitiatives. The ew welless ceter will iclude primary care, behavioral health services, a cultural trasformatio hub, ad both traditioal ad o-traditioal therapies. SPMC is actively seekig ways to trasitio from volume-orieted, fee-for-service ad costbased paymet models to value-based paymet arragemets. SPMC has partered with two local Medicaid Maaged Care Orgaizatios (MCOs) to create a value-based cotract that takes ito accout the size ad limitatios of the rural provider ad commuity. It icludes fudig for care coordiatio services ad metal health providers, ifrastructure support for SummitCare (a major welless iitiative at SPMC), ad fiacial bouses for reachig five quality metrics. The quality metrics were chose to be easy to collect ad relevat to the commuity. SPMC will have access to the MCOs data, which it hopes to use to moitor how well they are doig i reachig quality ad cost targets. SPMC also participates i a Medicare Shared Savigs ACO program. I order to build its capacity to participate effectively i this program, SPMC is workig o icreasig the iteral medicie activities of the hospital, usig hospitalists who do patiet cosults i the primary care cliics. The hospitalists are able to hadle much of the specialty care that would otherwise result i trasfers out of the commuity, to a larger regioal tertiary hospital; whe referrals are ecessary, SPMC s hospitalists look to sed patiets to parters with the best value care. By keepig care i the commuity, SPMC icreases the reveue ad patiet volume for both iteral medicie ad the primary care cliics. Jese advises that ay CAH plaig for the trasitio from volume to value-based health care start with icremetal steps that lay the ecessary groudwork, icludig a assessmet of the facility s capacity to deliver value-based care. She advises that hospital leadership eeds to be fully o-board ad that physicia champios are key for makig sure that projects are embraced. For more iformatio: http://cph.uiowa.edu/ruralhealthvalue/files/proactivelypursuigvbp.pdf PRIMEWEST HEALTH, MINNESOTA: Couty-owed Health Care Pla PrimeWest Health is a rural, couty-based health care pla owed ad govered by 13 couties i rural Miesota. Formed i 1997, PrimeWest Health provides health isurace coverage to couty residets who qualify for the state s Medicaid ad other medical assistace programs. PrimeWest Health curretly maages ad pays for services for over 36,000 people. The etwork of providers i the couty-based purchasig pla icludes medical, behavioral, allied health, ad social service providers. PrimeWest Health lauched its Accoutable Rural Commuity Health (ARCH) program i 2008 as a early Accoutable Commuities model that icorporates the priciples of shared risk ad savigs betwee the health pla, PrimeWest, ad its provider etwork. ARCH seeks to itegrate rural health care providers with local public health ad social service providers, through a patiet cetered medical home approach ad other iitiatives. ARCH established three fiacial icetives as part of the movemet to realig health care provider icetives: capacity developmet grats (e.g., grats to establish additioal oral health cliics i high Movig Rural Health Systems to Value-Based Paymet 7
demad areas), pay-for-performace bouses, ad paid shared savigs if overall health care (icludig public health ad social services) costs are reduced ad quality is improved. I additio, health care provider cotracts specify quality improvemet targets that providers are expected to meet. 7 ARCH seeks to reduce prevetable illesses ad utilizatio, icludig avoidable hospitalizatios, ad reduce uecessary health care costs. For more iformatio: https://www.primewest.org/aboutus http://cph.uiowa.edu/ruralhealthvalue/files/primewest.pdf IMPLICATIONS Cosideratios for Applicatio i Maie Rural providers affiliated with health systems i Maie are participatig i ACO ad other value-based paymet arragemets, though most are doig so usig traditioal paymet arragemets (e.g. fee-for-service ad cost-based reimbursemet). Although ot represetative of all rural providers i the state, their experiece with buildig care maagemet ad other capacities should be istructive to others. Paymet aloe is isufficiet for trasformig rural health care systems. As several of the examples discussed here idicate, rural providers ad commuities eed to carefully assess the health care eeds ad resources i their commuity ad their regio to determie how best to orgaize ad deliver services i a fiacially sustaiable system. Like others aroud the coutry, Maie s rural commuities ad providers may lack the capacity ad patiet volume to egage i value-based paymet ad delivery system trasformatio iitiatives. Parterships amog rural healthcare providers ca help build sufficiet capacity ad patiet volume to participate i these arragemets. The experiece of rural providers i Maie ad across the coutry idicates that practical, icremetal steps, such as workig o efficiecy improvemets, are essetial for buildig capacity for participatig i value-based paymet arragemets. Despite the growig adoptio of ew value-based paymet models, for the reasos metioed above, oly a miority of rural providers ad commuities are participatig i these arragemets. From the perspective of some rural admiistrators, this is just fie. Others, however, have oted that by ot participatig, rural health providers ad the commuities they serve are missig the opportuity to moderize ad improve their capacities to better serve their patiets. 8 I the absece of ew, more comprehesive paymet reform that recogizes the realities of rural health systems, rural commuities ad providers ca focus o preparig icremetally for the future by becomig more efficiet, buildig stroger care maagemet ad other capacity, ad carefully assessig services to esure a fiacially sustaiable future. Movig Rural Health Systems to Value-Based Paymet 8
Resources o the challeges of rural ACOs: https://www.ruralhealthifo.org/commuity-health/care-coordiatio/3/aco-modelimplemetatio-cosideratios https://www.ruralhealthifo.org/rural-moitor/rural-aco-leaders-speak/ https://www.public-health.uiowa.edu/rupri/publicatios/policybriefs/2015/rural%20 ACO%20Developmet.pdf http://www.cmedicaljoural.com/cotet/77/4/271.full REFERENCES 1. Ceters for Medicare & Medicaid Services. Accoutable Care Orgaizatios. https:// www.cms.gov/medicare/medicare-fee-for-service-paymet/aco/idex.html. Accessed September 27, 2016. 2. Letoureau L. Succeedig i a Brave New World: The Maie Commuity ACO. QC Blog. Vol 2016: Maie Quality Couts; 2016. 3. America Hospital Associatio. Illiois Rural Commuity Care Orgaizatio: Statewide Rural ACO. 2016. 4. MaieCare Services, Maie Departmet of Health ad Huma Services. Accoutable Commuities Iitiative. http://www.maie.gov/dhhs/oms/vbp/accoutable.html. Accessed September 27, 2016. 5. MaieCare Services, Departmet of Health ad Huma Services. Maiecare s Accoutable Commuities Iitatives. Jue 2015. 6. Rural Policy Research Istitute, Ceter for Rural Health Policy Aalysis. Rural Iovatio Profile: Proactively Pursuig Value-Based Paymet. Iowa City, IA: Uiversity of Iowa, College of Public Health; May 5 2016. 7. Rural Policy Research Istitute, Ceter for Rural Health Policy Aalysis. Rural Iovatio Profile: A Couty-Based Care Itegratio Model. Iowa City, IA: Uiversity of Iowa, College of Public Health; December 31 2013. 8. Mueller K, Alfero C, Cobur A, Ludblad JP, MacKiey AC, McBride TD. Medicare Value-Based Paymet Reform: Priorities for Trasformig Rural Health Systems. Rural Policy Research Istitute, Uiversity of Iowa; November 2015. The authors would like to thak iterviewees Dr. Barbara Crowley, James Davis, Michael Doahue, Reee Jese, ad Joa Orr for takig the time to speak with us about their work. Suggested citatio: Kah-Troster S, Cobur A. Iovatios i Rural Health System Developmet: Movig Rural Health Systems to Value-Based Paymet. Portlad, ME: Uiversity of Souther Maie, Muskie School of Public Service, Maie Rural Health Research Ceter; November 2016. Movig Rural Health Systems to Value-Based Paymet 9