The Centers for Medicare & Medicaid Services' (CMS) Quality Payment Program (QPP) rewards Medicare providers for high-quality, value-based care and requires providers to accept financial risk for their services. This policy brief summarizes non-metropolitan and metropolitan providers' participation in different QPP tracks and subdivisions and evaluates provider and patient-panel characteristics associated with financial risk acceptance.

Using 2018 CMS Merit-based Incentive Payment System (MIPS) eligibility and Alternative Payment Models (APM) participation data, this study analyzed non-metropolitan and metropolitan providers' participation in different QPP tracks and subdivisions including Accountable Care Organizations, MIPS APMs, and Advanced APMs. The healthcare payment framework to classify financial risk was adapted into four types: no risk, pay-for-performance risk, one-sided risk, and two-sided risk.

Key Findings:

• In 2018, a lower proportion of non-metropolitan providers participated in Advanced APMs with two-sided risk, compared to metropolitan providers.
• In both non-metropolitan and metropolitan areas, higher proportions of primary care providers participated in two-sided risk models than specialists.
• Non-metropolitan providers accepting no financial risk served fewer Medicare beneficiaries than non-metropolitan providers accepting financial risk. In contrast, metropolitan providers accepting no financial risk served more Medicare beneficiaries than metropolitan providers accepting financial risk.
• In both non-metropolitan and metropolitan areas, providers who accepted no financial risk received more than two times higher payment per beneficiary and had lower average Hierarchical Condition Category risk scores than providers accepting financial risk.