Authors: Greg Howe, Center for Health Care Strategies

What’s the issue?

People living in rural areas often lack access to high-quality, cost-effective specialty health care. Because most people prefer to receive care in their own communities from providers they trust, primary care providers in rural areas are best poised to fill this role. Project ECHO expands access to specialty care in underserved areas by equipping community-based primary care providers to deliver needed services — reducing reliance on referrals to specialists that often result in long travel distances and wait times.

Transforming Rural Health Care Through Medicaid Innovation Series

This resource is part of a series exploring how states can leverage innovative Medicaid approaches to improve rural health care delivery and strengthen access, workforce capacity, and sustainability in rural communities. LEARN MORE

The Medicaid connection.

Project ECHO is a telehealth mentoring model that strengthens workforce capacity in underserved areas by virtually connecting community-based primary care teams with specialists — often located in academic medical centers or larger health systems — to share evidence‑based strategies for managing patients. Medicaid members, in particular, face challenges accessing specialty health care, due in part to limited availability of specialists in their communities and long wait times. Across the U.S., Project ECHO has hubs in each state and operates more than one thousand programs, addressing a wide range of conditions, such as diabetes, heart disease, hepatitis, HIV, and behavioral health conditions.

How can the Project ECHO model support priorities of the Rural Health Transformation (RHT) Program?

States can use Project ECHO to support each of the RHT Program’s five priorities: make rural America healthy again, sustainable access, workforce development, innovative care, and tech innovation. RHT Program funds may be directed to these efforts through the program’s prevention and chronic disease and appropriate care availability categories, among others. The ECHO model is a learning framework that applies across disciplines — it is highly scalable and can be leveraged for additional conditions once the infrastructure is in place.

Opportunities and examples.

Project ECHO is an evidence-based model that leverages multi-disciplinary teams to build sustainable primary care capacity in local communities through a virtual hub-and-spoke approach. By adopting this model, states can more effectively use limited health care resources, achieve better outcomes, and honor patient care preferences.

States already support ECHO through a variety of mechanisms:

  • Funding through state appropriations. In some states, ECHO programs receive direct financial support through the general fund or as part of the Medicaid budget — providing stability for hubs and allowing broader program reach. Show-Me ECHO in Missouri, operated by the Missouri Telehealth Network at the University of Missouri School of Medicine, uses direct state appropriations and partnerships with Medicaid managed care organizations (MCOs) to offer ECHO services in every county in the state. The Oregon ECHO Network, operated by the Oregon Rural Practice-based Research Network at Oregon Health & Science University, is supported by community health plans and health systems that pay a fee. This funding model enables providers to participate in ECHO programs selected by the group.
  • Embedding ECHO in managed care payments. In New Mexico, ECHO is built into Medicaid managed care contracts. The state requires its MCOs to contract with the University of New Mexico Health Sciences Center, which operates ECHO programs statewide. Funding flows through a capitated, per-member, per-month rate, creating a dependable funding stream while allowing plans flexibility to tailor ECHO initiatives.

Key considerations for implementation.

States could consider using RHT Program funding to build on existing ECHO programs in their states to address the specific needs of rural communities. These funds can support ongoing operating costs, including for developing curricula, recruiting specialists, and expanding infrastructure. For long-term sustainability, states could explore a variety of financing approaches to support Project ECHO within their Medicaid programs.

Potential impact.

Over 800 peer-reviewed articles demonstrate the efficacy and sustainability of the ECHO model. For example, a study of people with hepatitis C found that patients treated by primary care providers participating in ECHO received care that was either comparable to, or in some cases better than, care delivered by specialists. Additionally, rural primary care practices and community health centers participating in ECHO improve care delivery and increase community provider retention. In addition to building clinical skills, Project ECHO Nevada found that participation also helped reduce providers’ sense of professional isolation. In New Jersey, Rutgers Project ECHO diabetes program demonstrated reduced health care spending and lower diabetes-related hospital admissions among Medicaid enrollees.

What’s next?

Officials can contact ECHO hubs in their states to learn about current offerings and the community needs they address. Some ECHO hubs offer programs across multiple states, like the University of Washington Medicine Project ECHO, which reaches providers in Washington, Wyoming, Alaska, Montana, and Idaho. Condition-specific collaboratives of ECHO hubs, such as the ECHO Diabetes Action Network, can also help identify relevant programs within and across states. With RHT Program resources, states can: (1) fund new and existing ECHO hubs through direct grants; and (2) promote long-term sustainability by incorporating ECHO funding into managed care capitation payments, as described above.

Additional resources for more information:

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