The Rural MACRA Experience

Research center:
Lead researcher:
Project funded:
September 2017
Project completed:
April 2019

The RUPRI Center for Rural Health Policy Analysis (RUPRI Center) proposed the Rural MACRA Experience project as a foundation for the RUPRI Center's rural healthcare payment focus. The new Medicare Quality Payment Program (QPP) is a critical component of the broader MACRA legislation. The RUPRI Center's project studied unique rural considerations of Medicare's QPP implementation and operation. Rural QPP considerations included provider eligibility, program preparation and data collection challenges, data analysis bias, and differential fiscal impact. MACRA included a performance-based provider compensation system (QPP) with yet unknown small and rural practices impacts. We hypothesized that small and rural practices would be differentially and negatively impacted by QPP.

This project informs policy makers, rural providers, and other key rural stakeholders regarding the rural impact of Medicare's new QPP. Many US providers must participate in the QPP, including rural providers. Since the QPP is just beginning, little is known about its relative impact on rural providers. However, due to a comparatively aged rural population, and thus a greater proportion of Medicare beneficiaries, providers serving rural areas may be disproportionally impacted by the QPP compared to urban counterparts.

Furthermore, new policy proposals to expand exemptions from QPP may leave small rural practices behind in the transition from fee-for-service to value-based payment. Exempted small rural practices may not have to opportunity to financially benefit from quality performance, may not be able to access QPP technical assistance, and may consequently be less inclined to accept new Medicare patients. Policy makers, rural providers, and other key rural stakeholders need answers to questions such as, "What are the unique rural barriers to QPP participation?" "What is the rural versus urban QPP participation rate?" "What rural bias exists in QPP performance data collection and interpretation?" "How will the QPP financially impact rural practices?" "How can the QPP be amended to reduce rural bias?" Thus, the results from this project will be of clear interest to FORHP and has broad applicability to multiple rural stakeholders. We proposed establishing the RUPRI Center as a primary resource for research evaluating QPP rural impacts.


  • Changes to the Merit-Based Incentive Payment System Pertinent to Small and Rural Practices, 2018
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2018
    This policy brief highlights key regulatory changes to the Merit-based Incentive Payment System that occurred in 2018. It discusses the implications of these changes with an emphasis on how these changes may affect small and rural practices.
  • Primary Care Clinician Participation in the CMS Quality Payment
    Policy Brief
    RUPRI Center for Rural Health Policy Analysis
    Date: 04/2019
    Approximately 10% of primary care clinicians participate in Advanced Alternative Payment Models (A-APMs) and less than 30% of primary care clinicians participate in the Merit-Based Incentive Payment System. Metropolitan primary care clinicians are more likely to participate in A-APMs than nonmetropolitan primary care clinicians.