Medicare has spent years trying to buy “value” the way someone buys a treadmill in January: with great intentions, a shiny dashboard, and a worrying chance that it becomes an expensive place to hang laundry. The Medicare Access and CHIP Reauthorization Act of 2015, better known as MACRA, was supposed to push the program away from paying for volume and toward paying for outcomes. In theory, that sounds excellent. In practice, MACRA has become a complicated machine that often rewards reporting skill more than clinical excellence.
The blunt argument is this: if Medicare truly wants value, it should cancel MACRA as it exists today and replace it with a simpler, more patient-centered physician payment system. Not tweak it. Not rename the forms. Not add another portal password that expires every Tuesday. Cancel the core structure and start again.
That does not mean abandoning value-based care. It means admitting that MACRA’s main pathway, the Merit-based Incentive Payment System, or MIPS, has become a maze. And in health care, a maze is not a strategy. It is an administrative burden wearing a policy badge.
What MACRA Was Supposed to Do
MACRA had a noble origin story. It replaced the unpopular Sustainable Growth Rate formula, which had threatened repeated Medicare physician payment cuts and forced Congress into yearly “doc fix” drama. Physicians wanted stability. Policymakers wanted accountability. Patients wanted good care without needing a graduate degree in federal acronyms.
MACRA created the Quality Payment Program, which offers two broad routes for clinicians. The first is MIPS, where clinicians are scored across quality, cost, improvement activities, and health information technology use. The second is participation in Advanced Alternative Payment Models, or Advanced APMs, where clinicians can earn incentives for taking on more accountability for cost and quality.
On paper, this was elegant. Reward clinicians who deliver better care at lower cost. Encourage coordination. Move beyond fee-for-service. Make Medicare smarter. Unfortunately, the lived experience has been far less elegant, more like assembling furniture with missing screws and a manual translated from policy language into another policy language.
The Central Problem: MIPS Measures the Measurable, Not Always the Meaningful
MIPS depends heavily on measures. Measures are not bad. Good measurement can expose gaps, improve safety, and help patients receive better care. The problem is that health care value is difficult to measure at the level of an individual physician or small practice. A patient’s outcome may depend on primary care, specialists, hospitals, pharmacies, family support, housing, transportation, income, and whether the patient can afford the medication after leaving the office.
Yet MIPS tries to translate a complex care journey into a score. That score then affects payment years later. The result can feel disconnected from clinical reality. A physician may spend extra time helping a patient understand diabetes medications, avoid an emergency room visit, and arrange follow-up care. But if the right box is not checked in the right format during the right reporting window, the system may not “see” the value.
That is not value-based care. That is paperwork-based care with a stethoscope nearby.
Administrative Burden Is Not a Side Effect; It Is the Product
One of the strongest arguments for canceling MACRA’s current structure is the burden it places on clinicians and practices. MIPS requires data collection, measure selection, documentation, software support, staff training, submission processes, performance review, and constant monitoring of changing rules.
Large health systems can hire compliance teams, consultants, analysts, and IT staff to keep the machine running. Small independent practices often cannot. Rural practices and solo physicians may feel the squeeze most intensely. When a program designed to reward quality becomes easier for large organizations to navigate than small community practices, Medicare should pause and ask whether it has accidentally built a consolidation engine.
The opportunity cost matters. Every hour spent chasing quality-reporting requirements is an hour not spent calling a patient after a hospital discharge, reviewing medications, coordinating with a caregiver, or simply catching up on sleep like a medically licensed human being.
MACRA Can Punish the Wrong People
Value-based payment must be careful with social risk. Physicians who treat poorer, sicker, or more medically complex populations may face lower performance scores for reasons outside their control. Patients with unstable housing, food insecurity, limited transportation, or multiple chronic conditions often need more support, not fewer resources.
If Medicare penalizes clinicians serving complex communities because their measured outcomes look harder to improve, the program risks punishing the very practices doing the most difficult work. That is like grading firefighters based on how smoky the building was when they arrived.
A smarter system would support clinicians who care for high-need patients. It would adjust payments for complexity, strengthen primary care, and reward care teams for solving real problems. MACRA’s current design has made some improvements over time, but patching an old roof during a thunderstorm is not the same as building a house that keeps people dry.
The “Value” Signal Is Too Weak
A payment system changes behavior when incentives are clear, strong, and credible. MACRA often fails that test. MIPS adjustments are delayed, complicated, and sometimes too small or too unpredictable to guide meaningful practice transformation. Advanced APM incentives have helped some organizations move toward accountable care, but participation can be difficult, especially for practices without infrastructure.
Medicare should not ask physicians to invest in care managers, data systems, patient outreach, and redesigned workflows while offering a confusing reward structure and unstable annual payment updates. That is not reform. That is asking someone to build a bridge while mailing them half a toolbox and a motivational quote.
True value-based care requires predictable investment. Primary care needs resources for longer visits, team-based care, behavioral health integration, chronic disease management, and after-hours access. Specialty care needs episode-based accountability where it makes clinical sense. Hospitals, post-acute providers, and physicians need aligned incentives. MACRA gestures toward these goals but does not reliably deliver them.
Canceling MACRA Does Not Mean Returning to Old Fee-for-Service
Critics may argue that canceling MACRA would mean surrendering to old-fashioned fee-for-service medicine. That would be a mistake. Fee-for-service still has obvious flaws. It can reward volume over coordination and procedures over prevention. But replacing one flawed system with another flawed system does not count as victory.
The better path is to cancel MACRA’s current framework and create a cleaner model. Medicare should keep what works: support for accountable care, practical quality measurement, patient-centered outcomes, and payment that recognizes complexity. It should discard what fails: excessive reporting, weak incentives, measure overload, delayed feedback, and scoring systems that clinicians do not trust.
In other words, do not cancel the mission. Cancel the machinery.
What Should Replace MACRA?
1. A Stable Physician Payment Update Tied to Practice Costs
Medicare physician payment should reflect the real cost of running a medical practice. Staff wages, rent, technology, malpractice coverage, supplies, and compliance costs do not politely wait for Congress to remember them. A stable update tied to practice cost inflation would reduce the yearly panic cycle and help practices plan responsibly.
2. Fewer, Better Quality Measures
Medicare should focus on a smaller set of measures that matter to patients: avoidable hospitalizations, medication safety, functional outcomes, patient experience, care continuity, and appropriate use of services. Measures should be clinically meaningful, risk-adjusted, and easy to collect from routine data whenever possible.
3. Stronger Support for Primary Care
Primary care is where value often begins. Good primary care prevents complications, catches problems early, manages chronic disease, and helps patients navigate the system. Medicare should pay for relationship-based care, not just face-to-face visits. Monthly care management payments, complexity adjustments, and team-based support would do more for value than another reporting checkbox.
4. Targeted Specialty Models
Not every specialty fits the same value-based model. Orthopedics, cardiology, oncology, nephrology, and gastroenterology face different clinical realities. Medicare should use targeted models where episodes, outcomes, and costs can be measured fairly. A hip replacement episode is not the same as managing multiple chronic diseases in a frail patient. Payment design should know the difference.
5. Real-Time Feedback Instead of Delayed Scorecards
Feedback that arrives a year or two later is not quality improvement; it is historical fiction with numbers. Clinicians need timely, actionable data. If Medicare wants practices to improve medication adherence, reduce avoidable admissions, or follow up after emergency visits, it should provide usable information while there is still time to act.
6. Equity Built Into Payment
A replacement for MACRA should explicitly support clinicians caring for low-income and medically complex Medicare beneficiaries. Safety-net add-on payments, stronger risk adjustment, and community-based care support would help Medicare reward value where value is hardest to produce and most urgently needed.
Specific Example: The Small Primary Care Practice
Imagine a small primary care practice in a rural county. The physicians know their patients by name. They manage diabetes, hypertension, heart failure, depression, arthritis, medication lists, transportation issues, family stress, and the occasional “I Googled this rash and now I think I have a medieval disease” appointment.
Under a better payment model, Medicare would support this practice with predictable base payments, care management funding, telehealth flexibility, and data showing which patients need outreach. Under MACRA’s current model, the practice may instead spend valuable time figuring out which measures to report, how to document improvement activities, and whether its EHR can successfully transmit data without turning into a digital raccoon in the ceiling.
The first model improves care. The second model improves the nation’s supply of exhausted office managers.
Specific Example: The Specialist
Now consider a cardiologist managing patients with heart failure. A meaningful value model could reward medication optimization, reduced avoidable admissions, timely follow-up after hospitalization, and coordination with primary care. The model would need accurate risk adjustment because some patients are much more complex than others.
A generic MIPS score may not capture that nuance. It may reward documentation more reliably than clinical improvement. The cardiologist may be judged by measures that only partly reflect the work that prevents a patient from returning to the hospital. Again, the issue is not that measurement is bad. The issue is that weak measurement can crowd out better judgment.
Why Medicare Should Be Brave Enough to Start Over
Health policy often treats complexity as sophistication. But complexity can also be camouflage. When a program becomes so complicated that only consultants can love it, policymakers should be suspicious. MACRA has had years to prove that its structure can deliver major improvements in quality and affordability. The evidence is not strong enough to justify the burden.
Canceling MACRA would be politically difficult. Many stakeholders have adapted to it. Vendors have built tools around it. Organizations have developed compliance routines. But adaptation is not proof of success. People also adapt to potholes by memorizing where to swerve.
Medicare should judge MACRA by patient outcomes, clinician trust, administrative simplicity, and cost-effectiveness. On those tests, the current system struggles. A replacement system should be simpler, faster, fairer, and more connected to actual care delivery.
Experiences Related to “If Medicare Wants Value, It Should Cancel MACRA”
The clearest lesson from years of value-based payment experimentation is that clinicians are not opposed to accountability. Most physicians, nurses, and practice leaders want better care. They want fewer avoidable hospitalizations, safer medications, stronger primary care, smoother referrals, and patients who can actually follow the treatment plan. What frustrates them is being asked to prove value through systems that often feel detached from the exam room.
In real practice settings, value is often created through small, human moments. A medical assistant notices that a patient missed two appointments and asks the care manager to call. A primary care doctor changes a prescription because the cheaper option is the one the patient will actually take. A nurse spends ten extra minutes explaining how to monitor weight after a heart failure discharge. A specialist calls the primary care physician instead of sending a vague note into the electronic abyss. These actions may prevent complications, but they are not always neatly rewarded by MACRA’s scoring architecture.
Practice managers often describe quality reporting as a second job layered on top of the first job. The first job is caring for patients and keeping the doors open. The second job is proving, through a rotating cast of measures and submission rules, that the first job happened. For large systems, this may be annoying but manageable. For small practices, it can be destabilizing. The same physician who is trying to recruit staff, negotiate rent, manage supply costs, and care for aging patients must also keep up with Medicare reporting changes. At some point, “value-based care” begins to feel like “value-based clerical survival.”
Patients rarely know the acronym MACRA, and frankly, they have enough acronyms already. What they notice is whether they can get an appointment, whether the doctor listens, whether the medication is affordable, whether the office follows up, and whether the care team sees them as a person rather than a chart with sneakers. A better Medicare payment system would start with those experiences and work backward. It would ask: what resources does this care team need to keep people healthier? What data would help right now? What outcomes matter to patients? What reporting can be eliminated because it adds noise rather than insight?
The experience of MACRA should teach Medicare humility. Not every good policy goal survives contact with operational reality. Paying for value remains the right destination, but MACRA’s route is too indirect, too burdensome, and too dependent on fragile measurement. The next model should be designed with fewer hoops and more trust. It should reward care coordination, strengthen primary care, support high-need communities, and give clinicians timely information. Above all, it should remember that value in medicine is not created by a scorecard. It is created when patients get the right care, at the right time, from a team with enough support to do the job well.
Conclusion
If Medicare wants value, it should cancel MACRA’s current framework and replace it with something clearer and more useful. The goal of value-based care is not wrong. The problem is that MACRA has made the road too complicated, the signals too weak, and the burden too heavy.
A better system would stabilize physician payment, strengthen primary care, support clinicians serving complex patients, use fewer and better measures, and provide timely feedback. It would reward care that patients can feel, not paperwork that only auditors can admire.
Medicare does not need more acronyms. It needs a payment model that helps doctors and patients spend less time wrestling with bureaucracy and more time improving health. Canceling MACRA would not be giving up on value. It would be the first serious step toward finally paying for it.
