M-RCBG Associate Working Paper No. 188

Washington Medicaid Innovation
Profiling Rural Regions for CHART Expansion

Simon Borumand


Executive Summary

This Policy Analysis Exercise aims to assist the Washington State Health Care Authority’s (HCA) Medicaid team in prioritizing rural regions for expansion of new healthcare payment models.

With a rise in rural hospital closings, and consistently poorer health outcomes in rural communities, change is needed to ensure that rural residents of Washington State have access to quality healthcare. As one of the largest purchasers of healthcare services in rural Washington, HCA has a unique opportunity to stem the financial difficulties that rural providers are facing and develop models that ensure rural patients receive the care they need.

To that end, HCA has been working on a rural health transformation plan in the North Central Region of Washington, using the Centers for Medicare and Medicaid Services (CMS) Community Health Access and Rural Transformation (CHART) Model. With CHART, HCA will pay healthcare providers a stable, predictable revenue stream, and in exchange, providers will take on financial risk for the population they serve. The increased financial stability should allow providers to invest in long-term services that directly improve the health of their communities, with a focus on behavioral and physical health integration, substance use disorder, maternal care, and broader social determinants of health.

The challenge faced by HCA is to balance the potential benefits of the new payment model against the current financial needs of the healthcare providers. Many rural healthcare providers are reluctant to engage in alternative payment models, fearing impacts on their clinics’ financial viability and ability to continue providing essential services in their communities. Conversely, those regions that may be most in need of health transformation are often those without the resources to make the substantive investments in infrastructure needed to manage patient health.

The goal of this report is to give HCA a series of metrics that they can use to understand a region’s viability for expansion of CHART. To that end, this report is broken into four main sections:

First, this report provides a high-level background on the condition of rural healthcare in Washington State.

This section describes how healthcare is purchased by Washington State’s Medicaid agency, gives an overview of the challenges facing rural healthcare delivery, and describes HCA’s rural health transformation efforts through the CHART Model.

Second, this report uses the metrics of the CHART Model to build a profile of the Better Health Together Accountable Community of Health region.

The key areas of focus for this report are the region’s demographics, key health outcomes (with a focus on mortality, behavioral health, and maternal health), and healthcare infrastructure. Detailed CHART-related data are housed in the appendix to this report.

Third, the report offers an analysis of the barriers to CHART expansion.

While a region’s health disparities may indicate a need for new healthcare approaches, the success of healthcare reforms will depend on the willingness and capability of providers in the region. To better quantify provider willingness, the report analyzes three main challenges to successful CHART expansion:

1. Financial Constraints: Can the health system financially support a shift in their payment models? 

2. Patient Populations: How do small patient populations and varied community needs impact the viability of a payment model based on state-wide budgets and priorities?

3. Leadership Resistance: What motivational and capacity constraints keep providers and hospital leaders from engaging with innovation efforts?

Fourth, the report suggests additional analyses that can be done to better understand a region’s readiness for healthcare transformation.

In each of the three categories outlined in the prior section, two key descriptive metrics are designated, and potential sources of data for analyzing those metrics are identified.

Armed with this report, the hope is that the HCA will be able to better understand a region’s viability for inclusion in the CHART Model. Additionally, the analyses and challenges pointed out in this report could give HCA ideas on how to amend the CHART Model to alleviate the key drivers of local hospitals’ reluctance to engage in rural health transformation efforts.

Download the paper in PDF format