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Summary of Perspectives of Physicians in Small Rural Practices on the Medicare Quality Payment Program

Core Content

This report presents the findings of interviews with physicians in small rural practices regarding their experiences with the initial implementation of the Medicare Quality Payment Program (QPP). The study was conducted by the RAND Corporation in 2017 and aimed to gather feedback on the QPP's rollout and flexibility provisions for small and rural practices to inform future federal rulemaking.

The QPP, launched under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), offers two payment pathways: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). MIPS is designed to reward clinicians based on quality, cost, and clinical practice improvement activities, while APMs shift payment models to value-based care and offer financial incentives and exemptions from MIPS.

The study focused on the challenges faced by small rural practices in participating in the QPP. Despite efforts to prepare, many physicians reported frustration with the lack of clarity in program details, late-determined requirements, and the significant effort required to comply.

Main Viewpoints

Concerns About the QPP

• Uncertainty and Complexity: Physicians expressed confusion and frustration over the program's structure, requirements, and the frequency of policy changes.
• Burden of Reporting: The administrative and technical burden of quality reporting was a major concern, especially for those with limited resources.
• Incentives and Exemptions: There was mixed feedback on the incentives and exemptions for small and rural practices, with some feeling they were insufficient to justify participation.

Suggestions for Improvement

• Clarify Requirements: Physicians called for clearer and more stable program guidelines to reduce confusion.
• Reduce Policy Changes: They requested fewer changes to the program to allow for better planning and preparation.
• Delay Implementation: Some suggested delaying the full implementation of the QPP for small practices to allow for more adequate preparation.
• Support for Vulnerable Populations: There was concern about penalizing practices that serve vulnerable or medically complex patient populations.
• Enhanced IT Support: Additional information technology (IT) support was recommended to help small rural practices meet the requirements.
• Virtual Groups: Physicians expressed interest in virtual group participation to pool resources and meet reporting thresholds, but also highlighted challenges in forming and managing these groups.

Key Information

Sample and Methodology

• Sample Size: A total of 20 interviews were conducted with physicians from small rural practices.
• Recruitment Methods: The study used a combination of stratified random sampling and referrals from CMS technical assistance contractors.
• Groups Studied: Four groups were identified based on eligibility and knowledge of the QPP:
  • Group 1: Eligible and knowledgeable, primary care
  • Group 2: Eligible and knowledgeable, specialty care
  • Group 3: Eligible but not knowledgeable, primary and specialty care
  • Group 4: Not eligible, varied knowledge, primary and specialty care

Response Rates

• Random Sampling: Low response rates were observed, with only 2% of practices contacted responding.
• Contractor Referrals: Higher response rates were noted, with 39% of practices contacted through referrals participating in the study.
• Overall Response Rate: The overall response rate was 5%, indicating a significant challenge in engaging small rural practices.

Policy Flexibilities

• Low-Volume Exclusions: In 2017, clinicians with less than $30,000 in annual Medicare-allowed charges or fewer than 100 unique Medicare patients were exempt from MIPS requirements.
• Virtual Groups: Proposed for 2018, virtual groups allowed small practices to pool reporting data, which was seen as a potential solution to the reporting burden.
• Transition Period: The transition period for MIPS was extended to 2021 under the Bipartisan Budget Act of 2018, providing more flexibility for small and rural practices.

Recommendations

The report highlights the need for future research to:

• Expand the Sample: Include a broader range of practices and specialties.
• Refine Recruitment Methods: Improve outreach to small rural practices to increase participation.
• Focus on Policy Impact: Investigate the long-term effects of QPP policies on small and rural practices.

Conclusion

The qualitative findings from this study offer valuable insights into the initial implementation of the QPP and the challenges faced by small rural practices. These findings can help interpret the first-year QPP results and guide future policy changes to better support these practices.

Key Terms

• QPP: Quality Payment Program
• MIPS: Merit-Based Incentive Payment System
• APMs: Advanced Alternative Payment Models
• MACRA: Medicare Access and CHIP Reauthorization Act of 2015
• NPI: National Provider Identifier
• EHR: Electronic Health Record
• TCPI: Transforming Clinical Practice Initiative
• QIN-QIO: Quality Innovation Network–Quality Improvement Organizations

Appendix Overview

• Appendix A: Describes the methods used to create the sampling frame.
• Appendix B: Provides detailed recruitment information by method and region.
• Appendix C: Includes full interview protocols for each group.