At this week’s Rural Health Policy Institute in Washington, DC, Caravan Health, the National Rural Accountable Care Consortium (NRACC), and other rural health experts and advocates gathered for a discussion about the role of data in rural health transformation. The energetic conversation raised promising research and policy questions for understanding what works best to improve quality of care for rural communities. Keep reading for a summary of the conversation and next steps.

Brock Slabach, Senior Vice President of NRHA, welcomed the group of about 20 rural health researchers, rural practitioners, and officials from federal agencies CMMI and HRSA. The group discussed how far rural providers have come in practice transformation, especially the transition to value-based payment models. This progress comes despite reluctance from  small and underfunded organizations to put their own limited funds at risk. Some early-adopting small and rural providers found success in the Medicare Shared Savings Program through the ACO investment Model (AIM) program from 2015 through 2018. While AIM showed strong results, the path forward for rural ACOs is affected by new rules that require all ACOs to take on risk more quickly.   

The key to health care transformation in rural communities is innovation. The group discussion touched on how rural practices are enthusiastic about adopting new population health measures such as annual wellness visits. The AWV is more than a traditional annual physical exam, it is a robust wellness survey including a health risk assessment and personalized prevention plan. In addition to health benefits to the patient, the AWV produces data that can be aggregated across patients to allow providers to focus on big picture questions about social determinants of health, care coordination, and chronic care disease management.  


John Sugden, Data Science Manager at Caravan Health, presented examples of data analysis made possible from CMS data files provided to the ACO. This includes specific and detailed information about patients, services, and diagnostic codes. John presented data about the costs that may be of concern to practices, such as ambulance costs and post-acute care. The data can help respond to specific areas of concern with high cost conditions or utilization patterns.   

John’s presentation led to a productive discussion about how utilization data can help rural providers understand the benefits of moving from fee-for-volume to fee-for-value.  Some of the questions that came up include: 

  • How can the data show practitioners and researchers how health care dollars are spent in rural practices? 

  • What does the data show us about whether care management actually works for either improving care quality or increasing cost efficiency? 

  • What are the barriers to accessing the large amount of available data? Even with those barriers, how can we make the best use of the available data? 

  • Rural hospitals facing financial stress may not be represented at this conference. How can this data reach them to help their financial position? 

  • Are there opportunities for CMS to release data more broadly to facilities that do not participate in MSSP

Special thanks to Robin Moody and Shannon Calhoun of NRACC who had the idea of bringing the group together to brainstorm about using data to tackle the serious health disparities we see in rural communities. Caravan Health provides subcontracted services to NRACC. 

We are interested to know how your practice makes use of the data you get from ACO participation. If you are a rural provider interested in learning more about how data analysis can help your practice, get in touch with us at

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