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CMS should exempt all-not just some-small practices from MACRA


The early verdict from physicians is simple: “MACRA? I think I know what that is, but I’ll pass, thank you.”

When payment reform under the Medicare Access and CHIP Reauthorization Act (MACRA) was unveiled last year, the government went out of its way to reassure small practices that they had nothing to fear. In fact, they made more than 800,000 physicians exempt from the program altogether as they didn’t treat enough  Medicare patients or collect enough in charges.


In case you missed it: Physicians, healthcare industry react to 2018 MACRA proposed rule


Then the Centers for Medicare & Medicaid Services (CMS) took it a step further, announcing “pick your pace,” where any participating physician-including solo and small practices still left in the program-simply had to submit one piece of data on their patients this year to avoid a penalty. If you submitted more data, you could also earn a bonus.

And the reaction was overwhelming from solo and small practice physicians: What’s MACRA again? 

In June, CMS unveiled its proposed rule for the program in 2018, affecting payments in 2020. They extended the exemptions-excluding another 134,000 physicians nationwide-and also eliminated “pick your pace,” requiring physicians to submit more data, but also giving flexibility in the volume and letting smaller practices submit the data they felt was most important.  

CMS is confident that this added flexibility will lure 90% percent of all Medicare-eligible practices (including solo and small practices) to participate. 


Quiz: How well do you understand MIPS?


The early verdict from physicians is simple: “MACRA? I think I know what that is, but I’ll pass, thank you.”

For some, they have no interest in becoming mass data producers for the government, likely meaning technological upgrades and staff changes. For others, they simply don’t think the metrics truly measure patient improvement. The reaction from smaller practices to MACRA has been tepid at best. 

Next: Here's a novel idea


Here’s a novel idea: Exempt all small practices from the program. Yes, all of those who aren’t already excluded due to patient panel or minimal charges, which is likely a small percentage of all practices that would participate anyway. 


Further reading: Slow and steady won't win the MACRA race for physicians


It’s clear the end game of the Quality Payment Program is to get large practices involved and control their costs while also improving care. Smaller practices shouldn’t have to play the same game as the larger practices they already compete against every single day when it comes to things like patients, resources and payer influence.

Don’t make the alleged “failures” of small practices fund larger practice payment bonuses.

Small practices face unique sets of issues-and CMS knows this. It’s time to embrace those issues and make a program that works for these physicians rather than push them toward consolidation or out of medicine. 


Keith L. Martin is editorial director of Medical Economics. Do you think MACRA is a good program for solo and small practices? Tell us at

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