Challenges in Previous Incentive Programs Will Continue Under MIPS for Small, Rural Practices

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While small and rural practices will likely perform better in the Merit-based Incentive Payment System (MIPS) than they have in previous programs, they will still be outpaced by larger practices. Stakeholders also outlined challenges they think will likely continue for these practices under MIPS.

Small and rural practices participating in the Merit-based Incentive Payment System (MIPS) will continue to face challenges experienced in previous payment incentive programs, and while these practices will likely perform better than they have in previous programs, they will still be outperformed by larger practices.

These findings are based on a report from the Government Accountability Office that looked at how small and rural practices performed in previous payment incentive programs—Physician Quality Reporting System (PQRS) and Value-based Payment Modifier (VM)—and projected the effect of MIPS on these practices. The report included interviews with 23 stakeholders about their views on challenges facing small and rural practices and outlined CMS' efforts to help these practices transition to MIPS.

According to 2015 PQRS data from CMS, both rural and non-rural small practices were roughly half as likely as larger practices to successfully participate in the program. Similarly, small practices were less likely to perform well in the VM program, based on 2015 data. While approximately 44% of small providers, both rural and non-rural, performed well in VM, 73% and 74% of larger practices in rural and non-rural areas, respectively, performed well.


According to CMS estimates of the projected effect of MIPS in year 1, small practices will experience more success in MIPS than they did in PQRS and VM in 2015. The agency estimates that 80% to 90% of MIPS-eligible small practices would receive a positive or neutral payment adjustment. However, larger practices are still expected to outperform smaller practices.

Speaking with stakeholders, the report identified 8 key challenges facing small and rural practices under PQRS, VM, and the Medicare Electronic Health Record Incentive program, also known as the Medicare Meaningul Use program:

  • Issues with electronic health record (EHR) functionality, operation and maintenance
  • Lack of EHR vendor support and timely updates
  • High costs of initial and ongoing investments needed for participation
  • Staffing issues, such as lack of financial resources to hire additional staff and lack of staff time to meet program reporting requirements
  • Issues with measures required for program participation that some providers felt were not aligned with patient care
  • Difficulties staying abreast of changes to program requirements and managing compliance with program requirements
  • Challenges associated with timeliness of feedback and program changes
  • Lack of provider control over certain performance metrics, such as those related to patient behavior

The report pointed out that while some challenges are unique or specific to small and rural practices, others are experienced by practices of all sizes but are particularly magnified for small and rural practices.

It also noted that stakeholders expressed concern that these challenges will likely carry over into MIPS to some degree. For example, having an EHR system may be needed to successfully participate in MIPS, and as a result, the technology challenges with maintaining and operating the system will persist.

Stakeholders made a variety of suggestions for CMS to implement to aid small and rural practice participation in the program, such as:

  • Providing timely information about program requirements
  • Increasing EHR functionality and standardization
  • Making relevant communication efforts, including making website updates apparent and creating opportunities for questions
  • Increasing the availability of personalized assistance for practices

According to the report, CMS has incorporated several strategies to offer flexibility and ease the transition from previous payment incentive programs, such as incorporating a transition period for cost performance, allowing providers to form virtual groups, and additional scoring or exceptions specifically for small practices. The report also mentioned outreach and educational efforts set forth by CMS, such as resources on the MIPS section of the Quality Payment Program (QPP) website outlining support available to small and rural practices, as well as a QPP Service Center and technical assistance contractors.