Special Topic: Fifty billion dollars, no scoreboard

Show Notes

Federal money is buying software for small rural hospitals. The program already demands four numbers for every initiative. One of them should be a patient, and it should be published.

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Fifty billion dollars, no scoreboard

Federal money is buying software for small rural hospitals. The program already demands four numbers for every initiative. One of them should be a patient, and it should be published.

Fifty billion dollars is going into rural health care, and the Centers for Medicare and Medicaid Services, which is handing it out, has put in writing that the results will not be published. The supporting statement says the information “is intended to be publicly available upon request.” It also says “the results of this collection will not be published.” A report you have to know exists before you can ask for it is not a public record of anything.

The Rural Health Transformation Program carries $50 billion, $10 billion a year through 2030, and every state has an award. In August the agency announced $93.3 million for Georgia, including money for telehealth, cybersecurity and surgical robotics, and for preparing 87 rural hospitals for value-based care. First-year awards averaged about $200 million a state, so the Ohio announcement that follows spends part of a sum already granted rather than adding to it.

On Oct. 16 the agency, known as CMS, announced $92 million for rural Ohio. The money splits three ways: $31.4 million for coordinated rural care networks, and $30.3 million each for maternal care and for equipment and facility upgrades at 22 rural hospitals. The agency's administrator, Dr. Mehmet Oz, said the focus now is on making sure “this early progress translates into lasting results for rural patients.” The release names no measure and no target.

That is the whole problem, and it is not for want of paperwork. The program's funding notice already tells each state to identify at least four quantifiable metrics for every initiative it proposes. It describes the technology category as information technology advances “designed to improve efficiency, enhance cybersecurity capability development, and improve patient health outcomes.” So the numbers exist. States propose them, the agency approves them, and nothing in the program's paperwork makes anyone publish how they turn out.

Some of it is going to artificial intelligence. Daniel O'Neil of Civic Operator, which tracks the program's grants, told Healthcare IT News in May that he had “counted approximately 23 states that specifically reference it in their plans,” a count of plans and not of dollars. Vermont offered its rural practices money for AI scribes. Its own list of activities sells the grant with a claim it does not source, that scribes “automate an average of over two hours of daily administrative work.” Its notice, KFF Health News reported, asks grantees to report how many clinicians and patients the software serves. Not how much time it saves. The sales claim is about hours. The reporting is about headcount.

The rules go further than the announcements do. One of the four metrics is meant to show how the effect is spread within the state. States are asked for baselines and targets “where possible” and milestones “if possible.” The post-award questions and answers repeat the four and require the agency's approval to add or drop one. States file three quarterly reports a year and an annual report. The first annual report was due on Aug. 31. The first quarterly report is due on Nov. 30.

And the scores matter. The Government Accountability Office reported on Oct. 6 that CMS requires those reports “that CMS will use to measure states' performance against states' milestones,” and plans to “convert states' progress implementing initiatives and policy actions into numerical scores” when it allots up to $40 billion more over four years. Half of that is split equally by law and a quarter follows rural factors fixed in 2025, so up to ten billion dollars will move on numbers that nobody is required to publish. CMS's state snapshots name each state's initiatives without their metrics. States must send their reports in but are not required to post them proactively. A CMS spokesman said the agency will publish an annual report on state progress. So far it has posted a tally of what states have obligated, which it says “is not a full view of state progress.”

State officials have a fair answer to all this. The money came with deadlines, and a small hospital closing a service cannot wait for a trial it has no staff to run. That is true. It is not an argument for measuring nothing. The reporting runs to 2031 and four metrics are required anyway, so the only live question is which four. Pick one a clinician would recognize. The share of eligible patients screened. The days from an abnormal result to the visit that followed. Either costs nothing extra at signing and neither can be reconstructed afterwards. That long-term outcomes take years is a reason to publish the near-term ones, not to skip them.

So here is the ask, and it is small. Make one of the four metrics for every technology initiative a clinical measure at the hospitals getting the tool, record a baseline before it arrives, and post it when the contract is signed. New Hampshire already posts its recipients' contracts, so that is the floor, not the ceiling. Few critical access hospitals have anyone whose job is to judge a surgical robot or a scribe, so pool the judging. One state agency or university center measuring two or three outcomes across twenty hospitals can answer in a year what none of them can answer alone. CMS holds the score that divides a quarter of the money still to come, and can withhold any of it from a state that strays from its plan. It should publish the reports behind that score, not only a summary of them, and set one short list of measures for technology so a result in Ohio means something in Georgia.

The 22 Ohio hospitals will have their new equipment for years. Whether rural patients were better off for it is a question someone will ask in 2031, when the last report comes due. On the paperwork as it stands, nothing guarantees anyone will be able to answer. Four numbers for each initiative, chosen now and published as they arrive, would be enough. That is the entire reform, and the four numbers are already in the rules.

Correction (Oct. 26): This article has been corrected. An earlier version said up to $40 billion could move on states' progress scores and that CMS's score releases the rest of the money. By law half of the remaining money is split equally among the states, and a quarter follows rural factors fixed in 2025. The scores set up to $10 billion, and CMS can withhold funds from a state that strays from its plan.

This special topic was read by an AI voice. Its sources are linked at physicianintheloop.org.