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Research Questions

  1. What are the views, expectations, interest, and understanding regarding QPP program participation among small rural practices?
  2. What feedback might physicians in small rural practices have on the initial implementation of the QPP?
  3. What potential future policies should be incorporated into the QPP to facilitate implementation by small rural practices?

The Centers for Medicare & Medicaid Services (CMS) recently launched its Quality Payment Program (QPP), which considerably changes the way physicians are paid under Medicare. There has been significant concern about the ability of small rural practices to successfully participate in the program. To address these concerns, RAND researchers conducted interviews with physicians in small rural practices on the initial implementation of the QPP in order to understand the flexibility provisions for small rural practices and to inform future federal rulemaking for the QPP.

The findings suggest that small rural practices are struggling to participate in the QPP. Interviewees reported frustration with a lack of clarity of program details, requirements that appeared to be determined late and were subject to change, and the amount of effort needed to participate. Interviewees suggested several changes to the QPP and Medicare policy to improve the ability of small rural practices to participate in the program. These changes included 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, 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.

Key Findings

Concerns about the ability of small rural practices to successfully participate in the QPP are warranted

  • Even physicians who were knowledgeable about the QPP and who were prepared to participate reported frustration with the lack of clarity of program details, requirements that appeared to be determined late and were subject to change, and the amount of effort needed to participate.

Interviewees suggested changes to the QPP to support small rural practices

  • Guidance provided in simpler language would be beneficial. Respondents mentioned difficulty answering questions about the effects of the QPP on their practices because they did not understand key requirements.
  • Because many practices were not aware of the need to report for the Merit-Based Incentive Payment System (MIPS) by October 2017 and because of the perceived lack of clarity and shifting requirements, respondents suggested that Medicare delay implementation of all or some requirements for small practices.
  • Respondents suggested avoiding penalizing small practices that serve vulnerable populations and that are least able to absorb payment reductions.
  • One respondent suggested that alternate methods of assessing physician quality, such as observational site visits, similar to teacher in-classroom assessments, would be less burdensome and more accurate for small rural practices.
  • Additional information technology support for small rural practices is needed, including for those that currently have electronic health record systems.
  • Soliciting rural practice input earlier in policy development would increase engagement of rural physicians and provide better understanding of the realities of small rural practices.


Additional research is needed to verify whether concerns identified by study participants are more widely shared among small rural and nonrural practices and to evaluate the extent to which changes in policies implemented since the study have addressed concerns

  • The sample frame could be expanded to add other types of respondents, including small practices in urban and suburban locations, MIPS-eligible clinicians other than physicians (e.g., nurse practitioners), small practices affiliated with health systems, and practices at the higher end of the "small practice" range (ten or more clinicians). This would provide a contrast with the range of small and very small practices included in this research effort.
  • The results of this study indicate that, in some cases, physicians' perspectives of available support might differ from CMS's goals. Interviews with technical assistance providers could provide useful insights that complement physicians' perspectives on technical assistance, particularly if they are conducted by an independent evaluator on a confidential basis and conducted with assistance providers rather than managers.
  • Several respondents indicated that they would retire, move to cash-only practices, or stop seeing certain Medicare patients to avoid the QPP. Analyses could be conducted to quantify the actual and potential effects of these responses on Medicare beneficiaries' access to care.
  • Site visits with selected small rural practices could supplement telephone interviews to provide richer information on how practices are responding to the QPP and the practice setting.

Table of Contents

  • Chapter One


  • Chapter Two


  • Chapter Three


  • Chapter Four

    Limitations of This Research

  • Chapter Five

    Recommendations for Follow-Up Research

  • Chapter Six


  • Appendix A

    Sample Frame Methods

  • Appendix B

    Recruitment Detail

  • Appendix C

    Interview Protocols

Research conducted by

The research described in this report was funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services and conducted by the Payment, Cost, and Coverage Program within RAND Health Care.

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