A November 2021 U.S. Government Accountability Office (GAO) report to Congress found that clinicians in rural, health provider shortage, or medically underserved areas continue to face financial, technology, and other hurdles in transitioning to alternative payment models. A smaller percentage of providers eligible to participate in Advanced APMs in rural or shortage areas participated in them each year from 2017 through 2019 compared to providers not located in these areas.
As part of their review, GAO officials analyzed CMS data for 2017 through 2019 and compared participation in Advanced APMs for providers in rural or shortage areas to providers not located in these areas. In addition, it assessed Advanced APM participation by provider type, such as physician, nurse practitioner, and physician assistant; by physician specialty, such as family practice, internal medicine, and orthopedic surgery; and by practice size.
GAO officials also interviewed CMS officials and obtained written responses from officials at the Health Resources and Services Administration. In addition, they interviewed officials from 18 stakeholder organizations that represent providers of various specialties who participate in APMs or have conducted research and are knowledgeable of issues related to APMs.
The data showed that 52,592 of the 442,927 providers in rural or shortage areas—about 12 percent—participated in an Advanced APM in 2019. In comparison, 174,140 of the 1,173,792 providers—about 15 percent—not located in these areas participated in an Advanced APM in 2019. However, GAO noted that participation in Advanced APMs among providers in rural or shortage areas increased at a faster rate than those not in those areas.
Among the key challenges GAO identified for Medicare providers in rural, shortage, or underserved areas are financial resources and risk management, data and health information technology, staff resources and capabilities; and design and availability of models.
On the technology front, stakeholders told GAO that providers in rural areas may be unable to conduct needed financial modeling or data analytics. One provider and a practice administrator who participated in stakeholder interviews said they would not have been able to analyze Medicare data without contracting with outside firms, which can be cost-prohibitive for small practices, according to another provider. “Providers in rural, shortage, or underserved areas may also lack the capability or time to conduct the financial modeling that would allow them to predict how they may perform in an APM before committing to joining one, according to some stakeholders,” the report said.
In addition, the complexity and cost of EHRs, or lack of high-speed internet to access them, may hinder EHR adoption among providers in rural, shortage, and underserved areas, the report said. Providers who do not use certified EHR technology may be unable to participate in Advanced APMs. One representative from a stakeholder organization told the GAO that EHR vendors charge practices the same price regardless of their size. “This provider also said that EHR vendors charge practices every time they interface their system with another practice’s EHR, and these charges can range in the thousands of dollars,” the report said. “In addition, one of the studies found that some providers in small, rural practices reported that EHRs cost more time, as documentation takes time away from patient care, and expense, such as high purchase, startup, and maintenance costs, than they appear to save. Beyond cost, providers in rural, shortage, or underserved areas may not understand how to use EHRs to their full capacity or may not know how to select the optimal software for their practice, some stakeholders said.”
Rural provides may have limited options of APMs or ACOs in which to participate due to their geographic or participant limitations, the GAO said, or because there is no APM or ACO in the area for them to join.
The GAO report also detailed the models CMS has implemented with features such as upfront funding for providers, technical assistance, and other elements, which may help providers in rural, shortage, or underserved areas, and small practices in these areas, transition to APMs, including Advanced APMs. For instance, the ACO Investment Model, which concluded in 2018, offered upfront funding to encourage ACOs to form in rural and underserved areas and to encourage existing ACOs to transition to APMs with greater financial risk.
