CMS has developed a variety of Medicare value-based payment models that tie payments to quality and efficiency metrics, and the importance of such models to physicians will increase under the new Quality Payment Program. The Government Accountability Office cautions, however, that small and rural physician practices face a number of unique challenges when participating in value-based payment models. A recent GAO report catalogues five particular areas of concern for small and rural physician practices, based on a literature review and stakeholder interviews:

Financial resources and risk management

  • Limited ability to take on financial risk because of relatively fewer financial resources/reserves
  • High costs of initial and ongoing investments for participation
  • Difficulties recovering investments in a timely manner

Health IT and data

  • Difficulties with data system interoperability and limited ability to access data outside of the practices’ own systems
  • Difficulties with training staff regarding electronic health record systems and with needed data entry, management, and analysis

Population health management care delivery

  • Patient preferences and geographic location affect ability to implement population health management care delivery and account for total care cost
  • Provider resistance to making adjustments needed for population health management care delivery

Quality and efficiency performance measurement and reporting

  • Difficulties with receiving timely performance feedback
  • Misalignment of quality measures between various value-based payment models and payers
  • Performance measurement accuracy for practices with few Medicare patients

Effects of model participation and managing compliance with requirements

  • Difficulties maintaining practice independence
  • Limited staff and physician time to complete required administrative duties
  • Difficulties with understanding and managing compliance with terms of fraud and abuse law waivers
  • Difficulties monitoring regulatory changes and complying with multiple value-based payment model requirements

The GAO notes that some small and rural practices have access to organizations that can help with challenges to participating in value-based payment models, including partner organizations that will share in financial risk. Nevertheless, small and rural practices may have financial resource limitations that prevent them from hiring organizations that can best assist them with participation.