Impact of Payment Policy on Access to Physician Care in Rural America

Research center:
Lead researcher:
Project funded:
September 2011
Project completed:
May 2013
Problem Statement: The ACA alters Medicare reimbursement through the Resource-Based Relative Value System (RBRVS) and bonus payments for primary care services. Specifically, the ACA provides a financial bonus if cognitive primary care services represent 60% or more of a primary care provider's practice. However, we hypothesize that many rural practices offer relatively more procedural services (such as endoscopies and exercise testing) because such services may not otherwise be available locally. Thus, rural practices may be less likely to reach the 60% threshold for cognitive primary care services. Policy makers and stakeholders need a service mix profile of rural practices so that policy changes do not either miss expectations (bonus payments not reaching targeted providers) or sacrifice local services (as small practices become part of integrated systems). We believe that physician payment policy will receive continued focus because of the need to fix long term problems (such as sustainable growth rate (SGR) and geographic adjuster issues). In addition, public policy must be developed that recognizes potential and real impacts on the access to, and delivery of, rural primary care services.

Goals, methods, and products: The first step of this project is to define the service mix of rural primary care practices. We will then assess the financial impact of current or proposed Medicare reimbursement changes on those practices. Since third party (private insurance) payment trends tend to mirror Medicare, we will also assess representative third party payments to rural primary care practices. Both national Medicare claims data and regional third party claims data will be used to define rural practice service mix and reimbursement change impacts. We will publish a Policy Brief that is a foundation for understanding differential and perhaps unintended policy consequences resulting from the use of specific codes to define primary care. We will develop a paper for submission to a scholarly journal that models the likely presence of physician practices with higher than expected (given expectations for composition of a primary care practice) percentages of their revenues being derived from procedural codes. Finally, we will build the capacity to model different policy proposals to modify payment based 12 on CPT codes, and develop a Policy Paper or Policy Brief using that model to assess the impact of current physician payment policies.