Dive Brief:

• Nearly one quarter of hospitals across the country were purposefully left out of some of the largest provisions of the Affordable Care Act. More than 1,200 rural, critical-access hospitals were not able to take part in Medicare's pay-for-performance programs and a majority are not taking part in accountable care organizations.
• These hospitals were left out mainly because of their logistics. Many provide high-quality care, but studies have shown that their death rates tend to be higher than at other rural hospitals. This could be because all of the acute care in isolated areas are funneled to these providers. Many of the hospitals also do not have enough cases of heart attacks and surgical procedures to reliably analyze their quality measures in these areas. Congress allowed them to be exempt from fines to protect the revenue of these hospitals that play an important role in their communities. 
• The ACA required testing to begin to understand how quality-based bonuses and penalties could work at these hospitals by 2012. Congress has yet to allot money to begin testing programs.

Dive Insight:

"Providers are reluctant when they have fragile financial status to participate in the program," Ira Moscovice, director of the University of Minnesota Rural Health Research Center, told Kaiser Health News. "(But) I think it's rather shortsighted to think you’re going to be excluded from this."

And some of these hospitals are finding ways to participate in ACA provisions on their own. Some providers are taking part in pay-for-performance programs with private insurers in their areas. Others are banding together with other rural hospitals to create their own ACOs.

Want to read more? You may enjoy this feature on the efficacy of rural care.