Health Reform WK-EDGE Impact of QPP program on physicians in small and rural practices
Thursday, February 28, 2019

Impact of QPP program on physicians in small and rural practices

By Vanessa M. Cross, J.D., LL.M.

While committed to serving Medicare beneficiaries, physicians practicing in small and rural communities are reporting that CMS's recently launched QPP program is creating a burden on the administration of their practices.

In a study entitled "Perspectives of Physicians in Small Rural Practices on the Medicare Quality Payment Program," commissioned by the HHS’ Office of the Assistant Secretary for Planning and Evaluation (ASPE), Rand Health looked into the impact of the launch of CMS's Quality Payment Program (QPP) on physicians in small and rural practices. RAND findings indicate that this sector is struggling with QPP, generally, and with its requirements that physicians participate in one of two quality-based payment tracks: (1) Merit-Based Incentive Payment System (MIPS) or (2) Advanced Alternative Payment Model (APM) (ASPE Report, February 8, 2019).

Background. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 144-10) created QPP. Under QPP, there are two paths for Medicare payments to clinicians: MIPS and APMs. MIPS provides financial incentives for eligible clinicians based on performance on quality, cost, clinical practice improvement activities, and use of electronic health records (EHRs). APMs are delivery and payment models that aim to shift performance-based financial risk from volume- to value-based care and payment. APM participants are exempt from MIPS and have the opportunity to earn bonuses. The ability of small rural practices to successfully participate in QPP has been a major concern of policymakers.

Results. The study's key findings report the following:

  • Small rural practices are struggling to participate in the QPP, especially the very small independent practices consisting of one or two clinicians serving the most rural, isolated, and vulnerable communities.
  • Practitioners knowledgeable about QPP reported frustration with a lack of program clarity, requirements determined late and subject to change, and the amount of effort needed to participate.
  • The QPP program itself was generally viewed as intrusive and burdensome, especially to practices that do not have EHR systems.
  • Few participants believed that MIPS would improve care quality or reduce physician's reporting or compliance burdens.
  • APMs were, for the most part, not considered a viable option by many respondents.
  • Several respondents considered QPP to be designed to put small independent practices out of business, whether intended or not. Many were committed to remaining in independent practice.
  • Many practitioners reported that their frustration with QPP would not impact the number of Medicare beneficiaries they would see in their practices.

Recommendations. Based on participants’ feedback, several changes were suggested to improve QPP, namely:

  • simplifying requirements and reducing burdens, generally;
  • clarifying and specifying program requirements;
  • reducing the frequency of program policy changes;
  • delaying program implementation for small practices;
  • avoiding penalizing small practices that serve vulnerable populations;
  • adjusting the penalty that small rural practices serving complex patients might receive, instead of adding bonus points;
  • developing less obtrusive methods for assessing the quality of care of small practices;
  • providing additional information technology support for small rural practices; and
  • enabling greater engagement of rural physicians by policymakers.

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