During the final negotiations of the COVID relief package from late December, 2020, Sen. Chuck Grassley (Iowa) led efforts to include modified language from the Rural Health Clinic Modernization Act. This language was included in the final bill, which does the following:

  • Raises the Independent RHC cap to $100 on April 1, 2021, and set to rise each year thereafter to $190 by 2028.
  • Newly established RHCs would now also be subject to the increased cap, which means that no new RHCs (even those purchased or established by hospitals with less than 50 beds) could receive uncapped cost-based reimbursement.
  • Uncapped RHCs in existence today would be grandfathered-in at their current All-Inclusive Rate and would still see year-over-year increases but would be constrained to their current AIR plus an adjustment for MEI (the Medicare Economic Index).
  • RHCs will now be allowed to bill for hospice attending physician services.

Although this is great news for independent RHCs, this may come at the cost of our provider-based RHCs. It does not appear that any clinics will have a reduction in their all-inclusive rate, which is a very important positive factor. But, this new language will prevent hospitals from establishing new RHCs and receiving the more lucrative uncapped AIR. Again, it’s important to note that this will not affect the AIR that any provider-based clinics are currently receiving…they are grandfathered-in to this new policy.

The board and legislative committee of the Alabama Rural Health Association will examine this language more closely and determine its effects to Alabama clinics. Stay tuned for more information.

HRSA E-mail to RHCs for COVID Reporting

We have received word that RHCs throughout Alabama recently received this notification from HRSA via e-mail. This is a follow-up to the requested attestation for funding received by RHCs from the CARES Act. Please be sure to comply with the reporting requirements in order to not jeopardize the funding that you received earlier this year in support of COVID response.

Dear Rural Health Clinic Administrators and Managers,

You are receiving this email because the Federal Office of Rural Health Policy (FORHP) within the Health Resources and Services Administration (HRSA), recently compiled an email list (RHC-COVID-19-TESTING-PROGRAM) of Rural Health Clinic (RHC) administrators and managers in order to better communicate Rural Health Clinic COVID-19 Testing Program information and updates.

The Paycheck Protection Program and Health Care Enhancement Act authorized the U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), to provide $225 million to RHCs for COVID-19 testing and related expenses. Beginning May 20, 2020, HRSA issued funding as one-time payments to RHC organizations of $49,461.42.

The terms and conditions for this program specify that, “The Recipient shall submit reports as the Secretary determines are needed to ensure compliance with conditions that are imposed on this Payment, and such reports shall be in such form, with such content, as specified by the Secretary in future program instructions directed to all Recipients.”  

To monitor and assess the program, HRSA has established a set of proposed measures that funded RHCs report back to HRSA at the Tax Identification Number (TIN) level. This brief set of proposed measures includes basic information on the RHC organization, the number of and location of testing sites (active and inactive), information on the use of funds, the total number tests conducted, and the number of COVID-19 positive tests. 

HRSA proposes to use this information to evaluate the effectiveness of the program at an aggregate level. As proposed, funded organizations must report the number of tests conducted and the number of positive tests on a monthly basis for the duration of the reporting period retroactively to May 2020. No personally identifiable, patient-level information is being requested.  

HRSA will be in contact with RHCs in the coming weeks with more information on the RHC COVID-19 Testing Reporting (RHC CTR) website, upcoming webinar, and other additional information. Please forward the email to the best contact for your RHCs COVID-19 Testing Program and cc: if you are the incorrect recipient. HRSA has funded the National Association of Rural Health Clinics to provide technical assistance to RHCs on the RHC COVID-19 Testing Program. If you have additional questions you may   

Trump Administration Announces Details of New Rural Health Model

The Centers for Medicare and Medicaid Services (CMS) recently unveiled the details of the Trump Administration’s long-awaited, new rural health payment model, the Community Health and Rural Transformation (CHART) Model. The CHART Model aims to, “[Unleash] innovation through new funding opportunities that will increase access and improve quality,” by allowing a limited number of rural health providers to participate in one of two tracks, the Community Transformation Track and the Accountable Care Organization (ACO) Transformation Track. According to CMS, this new model comes as a response to President Trump’s Executive Order on Improving Rural Health and Telehealth Access that was made on August 3rd, as well as the President’s Medicare Executive Order and CMS’s Rethinking Rural Initiative.

The Community Transformation Track will include up to 15 lead organizations. These lead organizations are entities representing a rural communities comprised of either a single county or a set of contiguous or non-contiguous counties. This track will create a $75 million grant program for the 15 organizations to share. This experimental track aims to give these up-front dollars to providers and allow them greater flexibility to create their own health care programs with a patient focus. 

The ACO Transformation Track builds on the successes the very popular and successful ACO Investment Model (AIM) program. In this model, CMS will select 20 rural-focused ACOs to receive advanced payments to engage in value-based payment efforts aimed at improving outcomes and quality of care for rural beneficiaries. We are supportive of this new and exciting opportunity, but we also want to acknowledge that how CMS currently sets spending benchmarks disadvantages certain rural providers. Currently, CMS compares the per-patient costs of a region’s ACO with the operating expenses of its non-ACO competitors, but rural ACOs are often the only significant provider in their region. Thus, rural ACOs often face a much lower spending benchmark, because urban and suburban regions often have more non-ACO providers. We are calling upon CMS to fix this ‘rural glitch’ within the MSSP. This is a critical and common-sense step towards establishing greater payment for rural providers that are providing high quality care to their communities while decreasing health care spending. Unlike the earlier AIM program, participants in the ACO Transformation Track will enter into two-sided risk arrangements as part of the Medicare Shared Savings Program (MSSP), which could be a barrier to entry for many rural hospitals unwilling to bear risk without being able to define that risk completely. Additionally, a CHART ACO is limited to 10,000 covered lives which could increase actuarial volatility in participating in a dual-sided risk program.

The timeline indicates that a Notice of Funding Opportunity (NOFO) for the Community Transformation Track will be available in September on the Model Website and the Request for Application (RFA) for the ACO Transformation Track will be available in early 2021.  

Status Report of the Alabama Primary Care Physician Workforce, 2019


Access to care is identified as Alabama’s number one health issue in the 2015 State of Alabama Community Health Improvement Plan, with the most significant and universal barrier being access to a Primary Care Physician (PCP).

In 2019 Alabama needs an additional 126 primary care physicians working 8 hours per day, 5 days per week located in 40 specific population centers to eliminate Alabama’s shortage of PCPs.

Alabama has one Full Time Equivalent (FTE) PCP for every 2,410.6 residents. This ratio globally suggests that Alabama has adequate numbers of PCPs available for its 4,850,771 residents, but in Alabama the PCP shortage is the result of the current distribution of PCPs and the lack of PCP access it creates.


This report identifies Alabama’s licensed primary care physicians (PCPs), their spatial distribution and their availability to Alabama residents. This model addresses access to primary care physicians at the community level while at the same time giving direction and allowing coordination at a state level.

The Office for Family Health Education & Research, UAB Huntsville Regional Medical Campus

  • William H. Coleman, MD PhD
  • Kyle Seigrist, PhD
  • Caleb Lenox, Research Associate
  • Alex Kearns, MS III

98% of Alabama’s PCP practices are located in 79 Alabama population centers.

These population centers are towns and cities where most Alabamians currently could or do obtain direct patient access to a PCP(s). These population centers are spatially located such that 96% of Alabama’s 4,850,771 residents are within a 30 minute or less travel time from one of these 79 population centers. The Alabama county map (Figure 1) shows the location of these 79 cities and towns and the practice locations of Alabama’s PCPs (green icons). Counties are geopolitical units, but they are not appropriate boundaries for defining population units (catchment areas) that can be linked to the 79 locations that house Alabama’s current PCP workforce.


Figure 2 shows Alabama’s 79 PCP population centers as points of access for residents in their catchment areas (Primary Care Service Areas or PCSAs). The boundaries of these PCSAs place each population center equidistant from all other population centers as measured by Alabama’s road network. PCSAs link PCPs in the network’s 79 towns and cities to their accessible populations in a manner that allows accurate calculation of PCP shortages based on local population demand. Towns and cities with shortages of PCPs in 2019 are denoted in red while centers in blue are population centers with an adequate number or a surplus of PCPs.


Using PCSAs instead of counties maintains Alabama’s usual designation of rural and urban areas and results in a more appropriate allocation of residents to rural or urban population centers, and PCPs, based on geographic accessibility. Figure 3 is an Alabama PCSA map color coded to identify rural and urban PCSAs, with 18 PCSAs designated as urban, and 61 designated as rural.


The results of Alabama’s PCP workforce analysis is presented in Figure 4. This table quantifies and details the results of Alabama PCP shortages in a concise, easily identifiable format. In summary, 40 population centers have a shortage of PCPs and 37 of these are rural. These population centers need a total of 126.3 additional FTE PCPs to eliminate the PCP shortage for the state as a whole. The other 39 population centers have adequate or surplus PCPs and 24 of these are rural. The PCSAs with a surplus have 493.2 more FTE PCPs than needed. In this table PCP shortages, adequate balance and surpluses are quantified at specific locations to identify not only how many PCPs are needed but also where they are needed.


98% of Alabama’s PCP practices are located in 79 Alabama population centers.

These population centers are towns and cities where most Alabamians currently could or do obtain direct patient access to a PCP(s). These population centers are spatially located such that 96% of Alabama’s 4,850,771 residents have 30 minute or less travel time access to PCPs. This map (Figure 5) shows the spatial distribution of Alabama’s towns and cities where Alabama residents have access to 98% of Alabama’s PCPs.



Alabama has 79 population centers identified as primary care service points based on PCP availability and population accessibility. The results table (Figure 4) serves as a template for focused needs evaluations, resource determinations and barrier assessment. It allows unique individualized community approaches, regional approaches where common issues among population centers exist, and realistic identification and consideration of issues that can to be addressed a state level.

Alabama population centers with shortages of PCPs are documented. The number of PCPs needed to resolve the shortages at these 40 population centers are documented. In addition Alabama’s FTE PCP statewide workforce is accounted for.

This analysis establishes that Alabama has a data-driven model with the capacity to accurately identify and quantify primary care workforce data, and produce annual updates. It serves as a tool to monitor outcomes and is able to project future needs based on PCP and population demographics. This model matches patient demand, based on average visits per year and average time per visit, with PCP availability, based on a standard physician workweek. Other models lack this specificity, which could result in different need computations, but most of these would identify the same service areas in need.


While this information is basic to understanding, accessing and addressing population center based shortage issues, the fact is, this information is not generally known. Thus the first step is broad-based dissemination of this information.