Medicare: Information on the transition to alternative payment models by providers in rural areas, with health worker shortages or underserved


What GAO found

In recent years, the Centers for Medicare & Medicaid Services (CMS) have developed and implemented new Medicare payment models, including Alternative Payment Models (APMs), with the goal of shifting from paying providers based on time. volume of care to the quality of care. care provided (value-based payments). One type of APM, advanced APMs, are designed to encourage providers to share both the financial rewards and the risks of caring for Medicare beneficiaries. Providers must meet certain requirements to participate in an advanced CPA, such as the use of certified electronic health record technology.

GAO’s analysis of CMS data revealed that a smaller percentage of providers eligible to participate in advanced CPAs (eligible providers) in rural or health worker shortage (shortage areas) areas participated. each year from 2017 to 2019 compared to service providers not located in these areas. .

Percentage of health insurance providers in rural or shortage areas and providers not located in these areas who participated in advanced CPAs, 2017 – 2019

Providers in rural, scarcely or medically underserved areas face financial, technological and other challenges when transitioning to CPAs, including advanced CPAs, according to CMS officials and stakeholders interviewed by the CPA. GAO. These included

  • a lack of capital to fund the initial costs of the transition to a CPA, including the purchase of electronic health record technology; and
  • challenges of acquiring or carrying out the analysis of the data necessary for participation.

CMS has implemented models with certain features that can help providers in rural, shortage, or underserved areas switch to APMs, including advanced APMs. This includes models that provide seed funding to help cover costs associated with participating in the MPA, such as hiring additional staff; and technical assistance, such as education on CPAs, to support providers.

Why GAO did this study

In 2017, in response to the CHIP Access to Medicare and Reauthorization Act 2015, CMS implemented the Quality Payment Program, a payment incentive program intended to reward care. efficient and high quality. The advanced APMs, which offer a 5% incentive payment to Medicare providers seeing a certain percentage of their Medicare beneficiaries through the advanced APM, are part of this program.

The CHIP Access to Medicare and Reauthorization Act 2015 included a provision for GAO to review transitions to APMs for providers in rural areas, areas of shortage, or medically ill areas. served. This report describes (1) participation in CPAs advanced by providers in rural areas or in scarcity; (2) the challenges faced by providers in rural, shortage or underserved areas in transitioning to CPAs, including advanced CPAs; and (3) the actions CMS has taken to help these vendors transition to APMs.

GAO analyzed CMS data on participation in advanced CPAs from 2017 to 2019, the most recent years available at the time of GAO’s analysis. GAO also interviewed officials from CMS and 18 stakeholder organizations that represent vendors of various specialties who participate in CPAs or who have conducted research and know about CPA issues.

The Department of Health and Human Services provided technical comments on a draft of this report, which GAO has incorporated where appropriate.

For more information, contact Michelle B. Rosenberg at (202) 512-7114 or [email protected]


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