Making MACRA Work for Patients and Physicians

As an ophthalmologist, I treat eye diseases, such as cataracts and glaucoma, which primarily impact our country’s oldest Americans. This means that when Medicare payments aren’t keeping up with the cost of providing care, specialty practices like mine are the first to notice.

Data from the Department of Health and Human Services bear this out: A recent Medicare Trustees Report found that physicians’ costs are expected to rise 2.2 percent annually and that current payment levels won’t keep up. The report predicts that low reimbursement rates may eventually create an access barrier for beneficiaries.

When Congress enacted the Medicare Access and CHIP Reauthorization Act in 2015, the intention was to repeal the flawed Sustainable Growth Rate and provide modest, positive Medicare payment updates. In addition, MACRA created two pathways to earn additional positive adjustments: the Merit-Based Incentive Payment System that would allow physicians to remain in fee-for-service and report on clinically relevant quality measures and activities; and Advanced Alternative Payment Models that would award participants with 5 percent annual bonuses.

For specialists like myself and other members of the Alliance of Specialty Medicine, payment updates to the conversion factor aren’t keeping up with inflation and are scheduled to cease for six years. Also, opportunities to participate in innovative models like A-APMS for specialty physicians such as ophthalmology, rheumatologists, urologists, dermatologists and others haven’t yet materialized.

Throughout the development and passage of MACRA, as well as technical corrections subsequently enacted in 2018, physicians have been appreciative of Congress’ willingness to listen to and incorporate our perspectives. The time has come for Congress once again to make some necessary adjustments to MACRA. Specifically, we’re asking that lawmakers extend the positive payment updates to the conversion factor and extend the 5 percent annual bonus for advanced alternative payment model participants.

Beyond the 5 percent annual bonuses to physicians who participate in A-APMs, Congress must press the Centers for Medicare and Medicaid Services to expand the number of alternative models available to specialty physicians. For physicians in rural areas, like myself, there often are not any available A-APMs. Physicians — particularly specialists — who may be interested in moving into these models, are stymied by their scarcity since the Center for Medicare and Medicaid Innovation has been slow in approving alternative models and has not been approving models developed by specialists.

Currently, only a small fraction of all physicians are considered qualified participants. For 2017, CMS reported that fewer than 100,000 reached QP status, as opposed to the million-plus physicians who successfully participated in MIPS, and we believe that the majority of these participants are primary care physicians. Most existing models are geared toward primary care, which makes specialty participation difficult. In fact, many APM entities actively discourage specialist participation.

Again, we thank Congress for repealing the SGR and replacing it with MACRA, which has maintained a viable Medicare fee-for-service option. Specialists want to see the law continue to work as it was intended, but to ensure continued success, Congress must ensure that physician payments keep pace with inflation by extending positive payment updates to the conversion factor.

At the same time, lawmakers can continue to encourage physicians to move toward A-APMs by encouraging CMS to expand the number of specialty-relevant models and by extending bonus payments for participation in those models. Specialists stand ready to work with Congress to ensure that Medicare beneficiaries continue to have access to high-quality care. 


Parag D. Parekh is an ophthalmologist from Pennsylvania and current chair of the Government Relations Committee for the American Society of Cataract and Refractive Surgery.

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