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.

Publications

• Assessing the Impact of Rural Provider Service Mix on the Primary Care Incentive Payment Program
  RUPRI Center for Rural Health Policy Analysis
  Date: 12/2013
  Under the Primary Care Incentive Payment Program (PCIP), if certain evaluation and management services represented 60% or more of Medicare allowable charges, the provider qualified for a 10% bonus calculated on the primary care portion of allowable charges. This brief assesses the impact of the rural provider service mix on the PCIP.
• Rural Implications of the Primary Care Incentive Payment Program
  RUPRI Center for Rural Health Policy Analysis
  Date: 06/2013
  This policy brief reports on eligibility among rural primary care providers for the Primary Care Incentive Payments established in the Patient Protection and Affordable Care Act.
• Variation in Primary Care Service Patterns by Rural-Urban Location
  Journal Article
  RUPRI Center for Rural Health Policy Analysis
  Date: 03/2016
  Examines primary care physician service patterns by rural-urban location and discusses effect on recruitment strategies for primary care providers in rural communities.