Patterns of Care in Small Rural Areas: Implications for New Models of Care Provision and Payment such as Bundled Payments and Accountable Care Organizations

Lead researcher:
Project funded:
September 2010
Project completed:
December 2014

Recent health reform has included a number of models of care provision and/or payment, for example bundled payments and Accountable Care Organizations (ACOs), which depend on linkages between different types of health care providers. The national discourse has built on the Dartmouth model of health care delivery, which divides the country into unique, non-overlapping service areas. While this conceptualization may be reasonable from the perspective of urban places, it is not known whether rural residents relate to a single urban hub for their healthcare, or utilize multiple hubs, possibly depending on the type of care needed or the provider that makes the referral.

It is difficult to assess whether new initiatives are reasonable for rural areas without a comprehensive understanding of current community patterns of care receipt. This two year study will describe usual patterns of care in rural areas, focusing on communities that either have no hospital, or only have a small hospital, so residents must travel outside the community for certain types of care. While there has been previous work looking at travel patterns for inpatient hospital services, our analysis will include all CMS-eligible providers, to determine whether rural areas are really part of a single service area, or whether smaller communities utilize services from a variety of larger hubs.

Questions to be answered are: Do small rural communities relate to a single hub or multiple hubs? And, can small rural communities be assigned to a single service area without major disruption of current patterns of care?

The results of this analysis will be used in a thought piece on how the concepts of bundled payments and ACOs might play out in small rural areas, and the implications and challenges of implementing these types of programs.


  • Rural-Urban Differences in Continuity of Care Among Medicare Beneficiaries
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 12/2014
    In response to the ACA and other reforms in the healthcare market, new care models are being tested and implemented. To addresses concerns that healthcare in rural areas may be more fractured and thus a difficult place for the models to succeed, we measured continuity of care using detailed data on a sample of Medicare beneficiaries from 2000-2009.