Bridging Care Gaps and Improving Access for Rural Members

As many as 20% of people in the US live in a rural area and are more likely to live with serious health conditions and die at a younger age than those residing in nonrural areas.

For health plans aiming to boost their performance in quality programs such as Healthcare Effectiveness Data and Information Set (HEDIS®) and Medicare Star Ratings, improving care for this vulnerable population is essential. By better understanding some of the key challenges that rural members face, plans can identify care gaps and achieve better outcomes while helping members enhance the quality of their lives.

Key Challenges for Rural Members

Several factors contribute to poor health outcomes among rural populations. These include:

• Access issues due to the national provider shortage. The scarcity of primary care, specialty care, dental, and mental health providers is especially acute in rural areas. For the 22% of rural Americans who lack broadband internet access, telehealth may not be a viable option. Members may simply forgo care because they don’t have access.

• Social determinants of health (SDOH) factors like lower incomes and lack of transportation options. Rural counties are hit harder by these and other SDOH factors. Many Medicare Advantage (MA) plans and dual-eligible special needs plans (D-SNPs), a type of MA plan for those eligible for both Medicare and Medicaid, offer SDOH benefits to members. In 2024, the SDOH benefits most offered by plans were financial assistance for food and produce as well as rent and utilities. Compared with their urban peers, rural beneficiaries are less likely to be enrolled in MA plans offering benefits for SDOH factors or long-term services and supports, such as help with bathing or housekeeping.

• Higher rates of obesity and behaviors linked to chronic disease. Obesity, tobacco use, physical inactivity, and alcohol use—all leading risk factors for chronic disease and premature death—are more prevalent in rural areas.

• Social and cultural issues that can affect health behaviors. Rural adults tend to have lower health literacy compared with urban adults, which can affect their ability to manage their care. For example, they may have difficulty understanding instructions for at-home colorectal cancer screenings or educational material that is not optimally designed to promote patient understanding. Many rural residents also mistrust health care institutions and public health interventions.

Strategies for Improving Access and Closing Gaps

While addressing these deeply rooted challenges requires a coordinated effort by providers, policymakers, payers, and other stakeholders, health plans can help close some of the care gaps so that members receive the care they need. This can also help plans improve their HEDIS and Star Ratings performance, which is based on clinical, operational, and member satisfaction measures across their urban and rural populations.

Here are key strategies to consider:

Target high-weight HEDIS and Star Ratings quality measures and identify opportunities for member education. A study conducted by the Rand Corporation for the Centers for Medicare & Medicaid Services (CMS) found that some of the largest deficits in clinical care for rural MA enrollees were for kidney health evaluations for patients with diabetes and osteoporosis screenings in older women. Rural MA enrollees also had lower rates of flu vaccination compared with urban enrollees.

Plans should identify gaps in their performance and risk-stratify their rural members using data on conditions, diagnosis, procedure, and severity. Multichannel outreach can then be developed to target past-due screenings and other preventative care measures to help close some of these gaps and drive behavioral change.

Help rural members enroll in the Low-Income Subsidy (LIS) program. The LIS program helps low-income Medicare beneficiaries pay for their prescription drugs under Part D. Rural members may especially benefit from the LIS program because a greater percentage experience poverty and difficulty affording prescription drugs compared with their peers in urban areas.

One large MA payer launched a targeted multichannel campaign to enroll eligible members in the LIS program. Of the 27 000 targeted members, 81% were reachable via interactive voice response (IVR) and 93% were reachable via text messaging. One-quarter of reached members connected with live agents, and 56% of LIS applications received through all channels were successfully completed.

Plans that adopt a similar approach to engage LIS-eligible members may help them lower their out-of-pocket drug costs and improve medication adherence and compliance, which impact Star Ratings.

Use health needs assessments to better understand rural members. When paired with geographical data, member-reported data on rural health risks can help plans identify vulnerable members and develop opportunities to address social factors that could impact outcomes. One large regional plan initiated 190 000 IVR calls to members to survey their SDOH needs, reaching 91% of targeted members. One-third of respondents reported concerns about food security, while 1 in 10 respondents worried about lack of reliable transportation.

To identify needs of rural members, consider adding survey questions such as:

• Do you live or work on a farm?

• Do you travel more than 1 hour to see your primary care provider/behavioral care provider/specialist

• Have transportation issues prevented you from attending medical appointments?

• Do you have high-speed internet?

• Do you feel socially connected to your community?

Collaborate with rural community groups to address SDOH and build trust. Outbound campaigns can direct members to a live agent who can help them access resources in their community. These could include mobile health clinics, transportation resources, and other social services and supports.

Partnerships with local pharmacies can also help drive immunizations, health screenings, and other interventions in rural areas. Pharmacists may also provide medication management, which can help improve adherence and drive better outcomes. Sponsoring educational events at schools and faith-based organizations—which often serve as community hubs in close-knit rural areas—can also help plans deliver health information in a way that builds trust. For inspiration, the Rural Health Information Hub offers several toolkits to support health promotion and outreach strategies with rural populations.

Empowering Members for a Healthier Future

Given the significant challenges facing rural communities, health plans should harness their creativity and tenacity when aiming to improve outcomes for their rural members. Plans that are willing to invest in targeted outreach efforts can boost their performance in critical quality improvement programs and provide their members with the resources needed to take control of their health care.

About the Author

Leah Dewey is Vice President of Clinical and Consumer Engagement Operations at Cotiviti. She is focused on improving health care outcomes by leveraging data and insights to close care gaps, improve consumer quality, and move population health across various cohorts and cultures.