Fred Ullrich, BA

RUPRI Center for Rural Health Policy Analysis

Phone: 319.384.3834
Email: fred-ullrich@uiowa.edu

Health Management and Policy
University of Iowa
College of Public Health
Iowa City, IA 52242


Completed Projects - (1)

Assessing the Stability of Rural Pharmacy Services
This project's goals include deepening our understanding of economic forces beyond the immediate control of local pharmacies that are affecting their ability to remain in business, assessing the future of sole community retail pharmacies in rural places, and exploring alternative modalities for delivering pharmacy services in the absence of retail pharmacy businesses.
Research center: RUPRI Center for Rural Health Policy Analysis
Topics: Health services, Pharmacy and prescription drugs, Telehealth

Publications - (35)

  • 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.
  • 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.
  • 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.
  • Causes and Consequences of Rural Pharmacy Closures: A Multi-Case Study
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2013
    Policy brief identifies factors that contributed to the closing of six rural pharmacies in different states and describes how the affected communities adapted to losing locally based services.
  • 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.

  • Characteristics of Rural Communities with a Sole, Independently Owned Pharmacy
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 05/2015

    In this policy brief, we characterize the population of rural communities with a single independently owned pharmacy. We find that over 2.7 million people, over 25 percent of whom live below the federal poverty level, reside in 663 rural communities with a sole independently owned pharmacy in 2014. For about 70 percent of these rural communities, the next closest pharmacy is more than ten miles away.

  • Demographic and Economic Characteristics Associated with Sole County Pharmacy Closures, 2006-2010
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2013

    This policy brief describes demographic and economic characteristics associated with counties experiencing closure of their sole pharmacy. Reports between May 2006 and December 2011 there were 296 rural communities that lost their only retail pharmacy, and nine communities that lost their only two pharmacies.

    Twenty-five counties lost their sole community pharmacy between May 2006 and December 2010. Among these:

    • The average population density is 10.4 persons per square mile, compared to 87.4 for the United States.
    • The average population decreased by 1.6% between 2000 and 2010. Excluding the largest county, the average decrease was 2.4%.
    • The population age 65 years and older increased 5.4% between 2000 and 2010. Excluding the largest county, the 65-and-older population increased 2.1%.
    • The average change in the percentage of persons in poverty increased by 0.6 points between 2000 and 2010, from 15.5% to 16.1%, compared to a 4.0 point increase (11.3% to 15.3%) for the United States.
    • The average percentage of people younger than 65 years without health insurance was 24.6% in 2010, compared to 16.2% for the United States.
    • Nineteen of the 25 counties were designated “whole county” Health Professional Shortage Areas (HPSAs), meaning there was a shortage of primary medical care physicians across the entire county.
    • The average number of active doctors per 1,000 persons was 0.44, compared to 2.86 for the United States. Six of the 25 counties (24%) had no active MDs or DOs in 2010.

    Recommendations: Policy makers might weigh the benefit of improved reimbursement policies to sole county pharmacies against the cost of little to no access to primary care health services, such as patient assessments, immunizations, and medication therapy management services, among rural residents.

  • 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.

  • Extent of Telehealth Use in Rural and Urban Hospitals
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2014

    Provides discussion with statistics on the use of telehealth in rural hospitals and the opportunities telehealth can bring to supporting healthcare in rural communities.

  • 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.

  • Financial Issues Challenging Sustainability of Rural Pharmacies
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2017
    Findings from a survey of rural lone community retail pharmacies about issues perceived as a threat to their sustainability. Reimbursement issues were cited as being most immediate and of highest magnitude.
  • Financial Performance of Rural Medicare ACOs
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2016
    Assesses the financial performances of rural accountable care organizations based on different levels of rural presence.
  • 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.
  • Independently Owned Pharmacy Closures in Rural America
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 07/2008

    The purpose of this policy brief is to provide policy makers, researchers, and stakeholders with information about the closure of rural independently owned pharmacies, including pharmacies that are the sole source of access to local pharmacy services, from 2003 to 2008. This period coincides with the implementation of two major policies related to payment for prescription medications: Medicare prescription drug discount cards were introduced on January 1, 2004, and the Medicare prescription drug benefit began on January 1, 2006. In this brief, we focus on rural pharmacy closure because of the potential threat such closures present to access to any local pharmacy services in a community. Funded by the Office of Rural Health Policy: Cooperative Agreement for Rapid Response to Issue-Specific Rural Research

  • Issues Confronting Rural Pharmacies after a Decade of Medicare Part D
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2017
    This brief reports on a survey of very rural independent pharmacies designed to assess threats to their sustainability. Major, immediate issues included delays in updates to maximum allowable costs (MACS), charges for remuneration fees, competition from mail order pharmacies; and, status as a “non-preferred pharmacy” for Medicare Part D plans.
  • Loss of Community Pharmacies Since 2006: State Experiences
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2009
    This brief presents the latest data from a continuous monitoring of the status of rural pharmacies by the RUPRI Center. Local rural pharmacies continue to serve many of the nation's communities as the sole provider of pharmacy services. However, between May 2006 and December 2008, the number of retail pharmacies in 213 rural places dropped from one to zero, and the number of retail pharmacies in 118 rural places dropped from more than one to only one. The brief includes a table showing the data by state.
  • 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: 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 Advantage Enrollment Update 2016
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2016
    This annual brief examines Medicare Advantage (MA) enrollment data from March 2015 and March 2016. It shows that enrollment in MA and other prepaid plans increased, both nationally and in non-metropolitan areas, but the rate of growth has slowed compared to previous years.
  • Medicare Advantage Enrollment Update 2017
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 08/2017
    Reports on the percentage of rural Medicare beneficiaries enrolled in Medicare Advantage (MA) plans and other prepaid enrollment plans. Compares national and rural MA enrollment, and variability by state.
  • 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.
  • Rural Bypass for Elective Surgeries
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2015
    Describes the elective surgical bypass rate, the procedures most commonly bypassed by rural residents, the distribution of volume among CAHs that offer elective surgical services, and factors predictive of bypass.
  • 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 Pharmacy Closures: Implications for Rural Communities
    RUPRI Center for Rural Health Policy Analysis
    Date: 01/2013
    Documents the closure of local retail pharmacies in which the pharmacist was the only clinical provider available in the community at the time the pharmacy closed, describing characteristics about the communities and retail pharmacies in question.
  • A Rural Taxonomy of Population and Health-Resource Characteristics
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2015

    This policy brief reports the newly developed taxonomy of rural places based on relevant population and health-resource characteristics; and discusses how this classification tool can be utilized by policy makers and rural communities. Using the most current data from multiple sources, we applied the cluster analysis to classify 10 distinct types of rural places based on characteristics related to both demand (population) and supply (health resources) sides of the health services market. In descending order, the most significant dimension in our classification was facility resources, followed by provider resources, economic resources, and age distribution. Each type of rural places was distinct from other types of places based on one or two defining dimensions.

  • Spread of Accountable Care Organizations in Rural America
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 10/2016
    This policy brief updates a RUPRI Center analysis of the presence of Medicare ACO’s in rural areas of the United States in 2013. Using participation data through 2015, the current brief finds that there has been broad growth in the number of places where ACO participating providers can be found, including rural locations.
  • Stand-Alone Prescription Drug Plans Dominated the Rural Market in 2011
    RUPRI Center for Rural Health Policy Analysis
    Date: 09/2012
    Reports that as of May 2011, 59.1% of rural Medicare beneficiaries were enrolled in Medicare Part D through insurance plans that provide coverage for prescription medications. Provides further detail of enrollment, including urban and rural enrollment by type of plan and by state.
  • Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2016
    Examines how Critical Access Hospitals perform compared to Prospective Payment System hospitals on measures of quality.
  • Surgical Services in Critical Access Hospitals, 2011
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 02/2015

    This brief describes the types and volume of major surgical services provided in Critical Access Hospitals (CAHs) across four regionally representatives states in 2011. Of the surgery volume performed in CAHs, on average 77% was performed on an outpatient basis and 23% inpatient. Operations on the musculoskeletal system, the eye, and the digestive system accounted for 67% of all surgical procedures performed in CAHs. Most reports of surgery volume in CAHs focus on inpatient procedures, thus missing a significant portion of the surgery volume that CAHs perform. CAHs offering outpatient procedures that complement inpatient surgical capacity are providing the communities they serve significant and valuable services through access to both convenient and emergent surgical care services that lessen many of the healthcare burdens associated with travel for surgery and follow-up care.

  • Telepharmacy Rules and Statutes: A 50-State Survey
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2017
    This is summary analysis reviews administrative rules and legislative statutes governing the practice of telepharmacy in all 50 states. Telepharmacy is specifically authorized in 23 states and 16 states have no rules or legislation authorizing telepharmacy. Other states have pilot programs or waivers that would enable telepharmacy.
  • 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.

  • Update: Independently Owned Pharmacy Closures in Rural America
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 06/2014

    Examines the closure of independently owned rural pharmacies in America from 2003-2013 and its effects on rural Americans’ access to medications and other pharmacy services. This report is an update to past publications from RUPRI.

  • 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.
  • Variation in Primary Care Service Patterns by Rural-Urban Location
    RUPRI Center for Rural Health Policy Analysis
    Date: 03/2016
    Examines primary care physician service patterns by rural-urban location and discusses effect on recruitment strategies for primary care providers in rural communities.