A. Clinton MacKinney, MD, MS

Deputy Director, Rural Telehealth Research Center

Phone: 320.363.8150
Fax: 319.384.4371
Email: clint-mackinney@uiowa.edu

Department of Health Management and Policy
University of Iowa
105 River Street, N200 CPHB
Iowa City, IA 52246


Completed Projects - (2)

Impact of Payment Policy on Access to Physician Care in Rural America
Profiles of physician practices will be constructed that specify the percent of payments derived from specific current procedural terminology (CPT) codes, dichotomized into evaluation and management (often considered to define primary care) or procedural. Differences across rural practices and between rural and urban practices will be analyzed, with implications for payment policies intended to reward rural primary care.
Research center: RUPRI Center for Rural Health Policy Analysis
Topics: Health services, Medicare, Physicians
Rural-Urban Physician Payment Differences Across the Nation: Methodological Changes
This project will simulate the effects of changes to the methodologies used to calculate the three geographic practice cost indices (GPCIs) currently used to adjust physician payment across the 89 Medicare payment areas in the U.S. and territories. Changes to the payment formula will be analyzed to determine potential impact on payment across areas and revenues for rural physician practices.
Research center: RUPRI Center for Rural Health Policy Analysis
Topics: Health policy, Medicare, Physicians, Workforce

Publications - (43)

  • Accountable Care Organizations in Rural America
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2013
    Reports that Medicare Accountable Care Organizations (ACOs) currently operate in 16.7% of all U.S. non-metropolitan counties.
  • After Hospital Closure: Pursuing High Performance Rural Health Systems without Inpatient Care
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2017
    A new paper describing opportunities for rural communities to develop a high performance rural health system after hospital closure, including three case studies that describe real-world transitions from hospital-based locus of care to new models of care delivery in rural places.
  • Are Primary Care Practices Ready to Become Patient-Centered Medical Homes?
    RUPRI Center for Rural Health Policy Analysis
    Date: 2013
    Measures the readiness of rural primary care practices to be eligible as patient-centered medical homes (PCHMs) by comparing PCHM readiness scores with metropolitan and nonmetropolitan primary care practices.
  • Area Wage Index of the Medicare Inpatient Hospital Prospective Payment System: Perspectives, Policies, and Choices
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2000
    This Policy Paper summarizes the positions of various rural health advocates and recording the actions taken by Congress and the Health Care Financing Administration (HCFA) to improve the wage index. Finally, it outlines the research needed to energize the policy discussion of the uses and methods of calculating the hospital wage index. Report produced by the RUPRI Rural Health Panel.
  • Assessing the Impact of Rural Provider Service Mix on the Primary Care Incentive Payment Program
    RUPRI Center for Rural Health Policy Analysis
    Date: 12/2013
    The Patient Protection and Affordable Care Act created the Primary Care Incentive Payment Program (PCIP). For the years 2011 through 2015, if certain evaluation and management services represent 60% or more of Medicare allowable charges, then the provider qualifies for a 10% bonus calculated on the primary care portion of allowable charges. Based on analysis of 2009 Medicare claims data, more than 70% of rural primary care physicians (PCP) and non-physician practitioners (NPP) qualify for payments. The average incentive payment for qualifying rural PCPs would result in an additional $8,000 in Medicare patient revenue per year. For qualifying NPPs, the result is an additional $3,000 in Medicare patient revenue per year.
  • Assessment of Proposals for a Medicare Outpatient Prescription Drug Benefit: The Rural Perspective
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2003
    This Policy Paper assesses legislative proposals to add an outpatient prescription drug benefit to the Medicare program and their implications for the delivery of services and the welfare of beneficiaries in rural areas. Report produced by the RUPRI Rural Health Panel.
  • Care Across the Continuum: Access to Health Care Services in Rural America
    RUPRI Center for Rural Health Policy Analysis
    Date: 12/2003
    Proposes that a continuum of care serve as the framework with which to consider rural healthcare policies, focusing on people and on places where people live rather than on the wants of providers and constituencies. The continuum of care describes the breadth of healthcare services in seven stages, from personal behavior to palliative care. The framework helps establish which healthcare services should be provided locally and which provided at a distance, emphasizing seamless linkages between all stages of the continuum.
  • Care Across the Continuum: Access to Health Care Services in Rural America (2006)
    RUPRI Center for Rural Health Policy Analysis
    Date: 2006
    The article is divided into 3 sections: 1) basic principles that determine services to be included in the continuum and how success in providing those services is judged; 2) definition of the continuum and its basic stages based on the health systems research literature; 3) applications of the continuum and policy implications of the framework.
  • Care Coordination in Rural Communities Supporting the High Performance Rural Health System
    Report

    Date: 06/2015

    Care coordination has emerged as a key strategy under new healthcare payment and delivery system models that aspire to achieve Triple Aim objectives—better patient care, improved population health, and lower per capita cost. Achieving these objectives requires conceptualizing and planning care delivery in a new way that not only involves coordinating medical care, but helping people get the care and the support services they need to address the “upstream” social determinants of health. In rural places, these are especially important considerations. While care coordination models vary, all include multidisciplinary teams and networks, a person-centered focus, and timely access to and exchange of information. The purpose of this paper is to examine care coordination programs and processes that affect rural people and places to discover what is happening now in rural communities, how different programs and approaches are working, who benefits, and make policy recommendations that will facilitate care coordination efforts in support of high performance rural health system development.

  • Characteristics of Rural Accountable Care Organizations (ACOs) - A Survey of Medicare ACOs with Rural Presence
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2015

    In this policy brief, we present the findings of a survey of 27 rural ACOs focusing on characteristics important to their formation and operation. We find that a majority of responding ACOs were formed from pre-existing integrated delivery systems and had physician and hospital participants with prior risk-sharing and quality-based payment experience. In addition, physician groups played a leading role in the formation and management of the ACOs.

  • Comments on the June 2001 Report of the Medicare Payment Advisory Commission: Medicare in Rural America
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2001
    Comments on and critiques the findings in MedPAC's Medicare in Rural America. The authors believe that while the MedPAC report helps set a framework for analysis, it is not a definitive treatise on the role of Medicare in rural health. Among its findings: most of MedPAC's recommendations would have positive impacts on health care for rural beneficiaries, others would do no harm, others could be strengthened, and a few, particularly those relating to access to services, "suffer from disparities and weaknesses." Report produced by the RUPRI Rural Health Panel.
  • The Current and Future Role and Impact of Medicaid in Rural Health
    Rural Policy Analysis and Applications
    Date: 09/2012
    Outlines and describes the current Medicaid program and its importance to rural America. Also discusses rural implications of program expansion, including whether and how states choose to implement changes.
  • Designing a Prescription Drug Benefit for Rural Medicare Beneficiaries: Principles, Criteria, and Assessment
    Maine Rural Health Research Center, RUPRI Center for Rural Health Policy Analysis
    Date: 08/2000
    The purpose of this paper is to offer a rural perspective on the current debate over the design and implementation of a Medicare prescription drug benefit. Background information on rural Medicare beneficiaries' need for, and access to, prescription drugs is provided, along with a set of rural-oriented principles for use in evaluating how different prescription drug proposals may meet the needs of rural beneficiaries. Report produced by the RUPRI Rural Health Panel.
  • Developmental Strategies and Challenges for Rural Accountable Care Organizations
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2015

    This Policy Brief shares insights into initial strategic decisions and challenges of four Accountable Care Organizations (ACOs) with a rural presence, one from each census region (West, Midwest, Northeast, and South). Semi-structured on-site interviews were conducted with ACO leaders and key stakeholder group representatives (e.g., board members, physicians). The four ACOs were formed as a step toward a value-driven rural delivery system, recognizing that ACO participation may not have a short term return on investment. Common value-enhancing strategies included care management, post-acute care redesign, medication management, and end-of-life care planning. The four ACOs also emphasized the importance of access to data for population health management, care management, and provider participation. While several challenges need to be addressed, these insights can inform development of other rural ACOs.

  • The Effect of Medicare Payment Policy Changes on Rural Primary Care Practice Revenue
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2014

    Describes the impact of recent Medicare payment updates to the Geographic Practice Cost Indices (GPCIs) portion of the Medicare Physician Fee Schedule (MPFS) on rural primary care providers’ practice revenue from Medicare. Using rural primary care provider Medicare claims from 2009 linked to the 2013 MPFS relative value units (RVUs), the 2013 GPCIs for non-metropolitan localities, and the GPCI updates from the Pathway for SGR Reform Act of 2013, we developed a revenue model to derive estimates of Medicare-related average revenue in 2013 and change-in-average-revenue percentage due to the GPCI updates for 50 non-metropolitan localities. Holding the conversion factor (CF) and RVUs fixed, we found that changes to the GPCIs made between January 1, 2013 and March 31, 2014 resulted in an average 0.12% (median 0.18%) increase in Medicare-derived revenue to rural primary care practices. Without the GPCI work floor reinstatement, however, primary care practices in rural areas would have been disproportionately negatively impacted through lower Medicare-related revenues.

  • Facilitating the Formation of Accountable Care Organizations in Rural Areas
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2014

    Presents characteristics contributing to the formation of four accountable care organizations (ACOs) that serve rural Medicare beneficiaries, one each of the four census regions (West, Midwest, Northeast, and South). Semi-structured interviews were conducted on-site with ACO leaders and representatives of key stakeholder groups (e.g., board members, physicians, information technology managers). Four organizational characteristics emerged as influential in the formation of these ACOs. First is previous organizational integration experience, which includes physician-hospital organizations, independent practice associations and mergers. Second is experience in risk-sharing arrangements, which includes participation in the Medicare Advantage program and insurance plan ownership. Third are information technologies, especially shared electronic health records, which enable several ACO capabilities. And fourth is developing partnerships with health and human services organizations in local and regional communities. These findings can help rural providers interested in forming or participating in an ACO assess the status and potential gaps of their core structures and capabilities.

  • From Health Care Volume to Health Care Value - Success Strategies for Rural Health Care Providers
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2014
    Examines strategies that rural healthcare providers can use to improve healthcare quality for patients.
  • The Frontier Extended Stay Clinic Model: A Potential Health Care Delivery Alternative for Small Rural Communities
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2013
    Describes how the Frontier Extended Stay Clinic model may be appropriate in rural communities other than the five original demonstration sites.
  • Health Information Technology Workforce Needs of Rural Primary Care Practices
    WWAMI Rural Health Research Center
    Date: 07/2014
    Assesses electronic health records and heath information technology workforce resources that are needed by rural primary care practices to manage the increasing patient populations.
  • The High Performance Rural Health Care System of the Future
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2011
    Describes a future rural system that would be built on foundations of affordability, accessibility, community focus, high quality, and patient centeredness.
  • Improving Prescription Drug Coverage for Rural Medicare Beneficiaries: Key Rural Considerations and Objectives for Legislative Proposals
    Maine Rural Health Research Center, RUPRI Center for Rural Health Policy Analysis
    Date: 06/2000
    This Policy Paper combines the work from current projects of the Maine Rural Health Research Center (MRHRC) and the Rural Health Panel of the Rural Policy Research Institute (RUPRI) to provide a statement of specific rural considerations and objectives for any proposal that would add a prescription drug benefit to the Medicare program. Our intent is to establish a framework for assessing the effects of proposals on rural beneficiaries. Report produced by the RUPRI Rural Health Panel.
  • Increases in Primary Care Physician Income due to the Patient Protection and Affordable Care Act of 2010--Continued Tweaking of Physician Payment
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2010
    The Patient Protection and Affordable Care Act (ACA) authorizes several changes to the Resource-Based Relative Value Scale (RBRVS) system that are designed to increase primary care physician personal income and reduce geographic variation in primary care payment. In this brief, the ACA-authorized primary care payment adjustments are modeled in a prototypical rural primary care practice to assess both the potential impact on physician personal income and the likelihood that the changes will achieve the desired policy outcome.
  • Medicare Accountable Care Organizations: Beneficiary Assignment Update
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2016
    This brief updates Brief No. 2014-3 and explains changes in the Centers for Medicare & Medicaid Services Accountable Care Organization regulations issued in June 2015 pertaining to beneficiary assignment for Medicare Shared Savings Program ACOs. Understanding ACO beneficiary assignment policies is dire in managing ACO providers and beneficiaries.
  • Medicare Accountable Care Organizations: Program Eligibility, Beneficiary Assignment, and Quality Measures
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2014

    Discusses the Medicare Shared Savings Program (MSSP) eligibility, participation requirements, and quality measures relative to Accountable Care Organization (ACO) formation.

    Recommendations: Organizations considering participating in the MSSP (Medicare ACO program) should carefully review program eligibility requirements and the beneficiary assignment process. Due to beneficiary assignment based on the greater of allowed Medicare charges, new Medicare ACOs may discover fewer assigned beneficiaries than anticipated. Potential shared savings will be reduced by suboptimal quality Therefore, new Medicare ACOs must provide excellent care in 33 outpatient clinical quality and patient satisfaction measures to a void shared savings reduction.

  • Medicare Accountable Care Organizations: Quality Performance by Geographic Categories
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2016
    This brief provides an analysis of the differences in ACO performance on the quality measures among the Medicare Shared Saving Program (MSSP) ACOs with varying levels of rural presence. Findings suggest that ACOs with a significant rural presence have performed as well as, if not better than, urban ACOs in delivering quality care.
  • Medicare Beneficiary Access to Primary Care Physicians -- Better in Rural, but Still Worrisome
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2011

    Primary care is the foundation of the rural U.S. health care system. Thus, the willingness of rural primary care physicians to accept new Medicare patients is critically important to the Medicare program and to rural America's elderly. In this policy brief, results from a large national physician survey are used to assess U.S. primary care physician and general surgeon willingness to accept Medicare patients and physician-reported reasons for not accepting Medicare patients.

  • Medicare Physician Payment
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2003
    Examines how the Resource-Based Relative Value Scale (RBRVS) has replaced the 25 year-old Medicare CPR charge system.
  • Medicare Physician Payment Policy and the Rural Perspective (Final Report)
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2008
    During the past six years, the RUPRI Center has examined the effects of Medicare payment changes on rural physician practice revenue. Despite the apparently tenuous association between Medicare physician payment policy and physician practice decision making, we infer that changes to practice revenue potentially affect physician decisions regarding rural practice. This report presents the results of the RUPRI Center's work and provides a framework for understanding this continuing policy question.
  • Medicare Physician Payment: Impacts of Changes on Rural Physicians
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2006
    Overview of the effects of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 on physician payment rates in rural areas. Discusses the effects of the Medicare incentive payment (MIP) for providing services in shortage areas and of the bonus for practicing in a physician scarcity area.
  • Medicare Physician Payment: Practice Expense
    RUPRI Center for Rural Health Policy Analysis
    Date: 10/2003
    Examines the physician practice expense component of Medicare payment, which proportionately results in greater geographic physician payment variation than does the physician work payment. The practice expense adjustment methodology warrants careful validation to demonstrate that the index measures actual geographic practice cost differences. A complete understanding of the reasons for different payments will inform both physicians who want to know why the same procedure results in less reimbursement in one place than it does in another and policymakers who want to address that concern.
  • Medicare Value-based Payment Reform: Priorities for Transforming Rural Health Systems
    Report
    RUPRI Center for Rural Health Policy Analysis
    Date: 12/2015

    In January, 2015, Department of Health and Human Services (HHS) Secretary Burwell announced new goals and timelines for moving Medicare reimbursement from fee-for-service to value-based payment. These payment changes are driving delivery system reforms (DSR) by making health care organizations more accountable for patients’ health as well as population and community health. Payment and delivery system reform, however, is concentrated in urban centers, and Medicare rural payment policies that were designed to strengthen rural health providers and systems are now complicating payment and delivery system reform in rural areas. The inclusion of rural providers in Medicare payment reform is critical for the program and for the 23 percent of Medicare beneficiaries who reside in rural areas. Rural Medicare beneficiaries should have the same opportunity as their urban counterparts to benefit from payment reform’s positive effects including strengthened primary care, embedded care coordination, and improved clinical quality. In this paper, we describe five recommendations to facilitate rural inclusion in value-based payment and delivery system reform:

    1. Organize rural health systems to create integrated care.
    2. Build rural system capacity to support integrated care.
    3. Facilitate rural participation in value-based payments.
    4. Align Medicare payment and performance assessment policies with Medicaid and commercial payers.
    5. Develop rural appropriate payment systems
  • Patient Protection and Affordable Care Act of 2010: Impacts on Rural People, Places, and Providers: A First Look
    Rural Policy Analysis and Applications
    Date: 09/2010
    Summarizes six issue areas of the Affordable Care Act (ACA) and discusses implications for access to services and improving the health status of rural residents. These issue areas are: health insurance coverage; Medicare and Medicaid payment; quality, financing, and delivery system reform; public health; healthcare workforce; and long-term care.
  • Patient-Centered Medical Home Services in 29 Rural Primary Care Practices: A Work in Progress
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2011
    Discusses survey responses from 29 rural physician practices from around the country. When asked about their use of specific policies and procedures that are included as criteria to certify patient-centered medical homes, fewer of them would qualify in each of five domains, including access to care, population-based, quality, care management, and clinical information management.
  • Redesigning Medicare: Considerations for Rural Beneficiaries and Health Systems
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2001
    Provides a framework to help shape proposals to redesign Medicare to the benefit of rural beneficiaries and providers. Chapters focus on equity, quality, choice, access, and cost. Each chapter outlines the current situation, analyzes the implications of various approaches to changing the program, and makes recommendations for developing a Medicare program of greatest benefit to rural residents. Report produced by the RUPRI Rural Health Panel.
  • Redesigning the Medicare Program: An Opportunity to Improve Rural Health Care Systems?
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2000
    With this paper, the RUPRI Rural Health Panel is presenting a well-defined framework for what should be included in any discussion of Medicare policies.
  • Rural Assessment of Leading Proposals to Redesign the Medicare Program
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2000
    This Policy Paper provides a critique of two proposals to redesign the Medicare program: the "Medicare Preservation and Improvement Act of 1999" (S. 1895, introduced by Senator Breaux and others) and "The President's Plan to Modernize and Strengthen Medicare for the 21st Century." Rural implications of the proposals are discussed, specifically how they affect rural Medicare beneficiaries and rural providers of health care services. Report produced by the RUPRI Rural Health Panel.
  • Rural Implications of the Primary Care Incentive Payment Program
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2013
    Reports on eligibility among rural primary care providers for the Primary Care Incentive Payments established in the Patient Protection and Affordable Care Act.
  • Rural Physicians' Acceptance Of New Medicare Patients
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2004
    Findings from analyses of national survey data of urban and rural respondents, published studies, and results of a survey of state organizations representing physicians indicate that: 1) The trend among all physicians is to not accept new Medicare patients, 2) The percentage of physicians in both urban and rural areas who are accepting new Medicare patients is declining, 3) Physicians practicing in rural areas not adjacent to urban areas are the most likely to accept new Medicare patients, and 4) Findings also indicate that the negative implications of not taking the necessary steps to reverse the small but important decline in physician willingness to take new Medicare patients may be most serious in rural communities.
  • Rural Primary Care Physician Payment 2006-2009: What a Difference Three Years Doesn't Make
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2009
    The analysis in this brief shows the impact of Medicare's Evaluation and Management (E&M) service valuation adjustment (implemented January 1, 2007) on two prototypical primary care practices--one providing only E&M services and the other providing a mix of procedures and E&M services.
  • Securing High Quality Health Care in Rural America: The Impetus for Change in the Affordable Care Act
    Rural Policy Analysis and Applications
    Date: 12/2010
    The ACA calls for the development of a National Health Care Quality Strategy and Plan (National Quality Strategy) that will affect healthcare that is delivered to millions of Americans who live in rural areas and thousands of healthcare providers who care for them.
  • Trends in Hospital Network Participation and System Affiliation, 2007-2012
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 2014

    Network participation and system affiliation represent two viable ways for hospitals to build and/or access necessary capacities to engage in the transformation to an integrated, patient-centered, pay-for-value model of care delivery. This policy brief tracks trends in network participation and system affiliation among U.S. general community hospitals from 2007 to 2012. Network participation increased in larger hospitals, non-government not-for-profit hospitals, and metropolitan hospitals. System affiliation generally increased in hospitals of all sizes and types. However, there are notably higher percentages of system affiliation among midsized and large hospitals, investor-owned hospitals, and metropolitan hospitals compared to their counterparts.

  • Understanding the Impacts of the Medicare Modernization Act: Concerns of Congressional Staff
    Maine Rural Health Research Center, RUPRI Center for Rural Health Policy Analysis, Upper Midwest Rural Health Research Center
    Date: 2005
    The most efficient mechanism for research to affect policy is to provide policy makers with information on issues about which they have voiced concern. The Rural Policy Research Institute's Health Panel conducted 2 focus groups with 16 congressional staff in 2004 to identify a set of researchable questions concerning rural healthcare.
  • Use of Health Information Technology in Support of Patient-Centered Medical Homes Is Low Among Non-metropolitan Family Medicine Practices
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2011
    By creating a medical home program within Medicare, the Patient Protection and Affordable Care Act of 2010 gave momentum to growing interest in the concept of a patient-centered medical home (PCMH). Are physician practices, especially non-metropolitan primary care practices, ready to become PCMHs? We use a nationwide survey of physician practices to partially answer this question, focusing on the use of health information technology.