Ambulatory surgery centers (ASCs), like other healthcare providers, are waiting to see how expected change or repeal of the Affordable Care Act (ACA) might affect MACRA, surgeons, and ASCs. Some experts predict:

  • surgeons should prepare to make the change required under MACRA, at least until more information is available;
  • MACRA has two new payment systems: the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs);
  • under the quality measures, some surgeons will win while others will lose.

The Affordable Care Act (ACA) did not affect ambulatory surgery centers (ASCs) as much as hospitals, physicians, health clinics, and other providers. It is possible that a repealed or revised ACA also will have a lesser effect on ASC operations.

But the ACA and Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are designed to affect all healthcare facilities, including same-day surgery centers, in the areas of safety, quality of care, and patient outcomes. One method is through the Merit-based Incentive Payment System (MIPS).

The ACA has so many tendrils, no one — including President Donald Trump’s administration — can say exactly what will happen when some are severed. For instance, how might MACRA change?

“We don’t think the [new] administration has fully appreciated all of the many provisions that are in the Affordable Care Act,” says Frank Opelka, MD, FACS, medical director of quality and health policy at the American College of Surgeons.

“There are well over 300 provisions in that law, along with a lot of supporting regulations,” Opelka says. “We think they are going to have to be thoughtful about what interfaces with a bicameral, bipartisan bill like MACRA.”

MACRA provides two new methodologies for paying physicians. CMS provides the following two tracks from its quality payment program:

  • the Merit-based Incentive Payment System (MIPS), and
  • Advanced Alternative Payment Models (APMs).

MACRA has taken the place of the sustainable growth rate (SGR) formula for setting Medicare’s physician payment rates, says Keith S. Naunheim, MD, professor of surgery at Saint Louis University School of Medicine in St. Louis.

“It will no longer be a yearly fight over a possible 20% cut,” Naunheim says. “It’s allowing for a 0.5% increase each of the next three years, so there won’t be any cuts.”


The big change under MACRA is the way in which Medicare will evaluate physicians. There are bonuses and penalties built in to the quality payment program, he says.

“The alternative payment model is not available to most thoracic surgeons unless they’re already a member of an accountable care organization,” Naunheim says. “The Society of Thoracic Surgeons has been working with Medicare to try to get them to allow us to put together a specialty-specific alternative payment methodology, and those negotiations are still ongoing.”

Because of the high staff turnover at CMS, efforts likely are slowing, he notes.

“The person we had done a great deal of communicating with may not continue, so we’ll have to start over again,” Naunheim says.

It’s likely that for at least the next two years, almost all thoracic surgeons will be lumped into the MIPS program, he adds.

The American College of Surgeons and the Society of Thoracic Surgeons have been working to educate surgeons about MACRA and how to participate successfully in MIPS, even as the future of these is uncertain.

“We have to go with what’s on the books, and what’s on the books is MACRA APM and MIPS methodology,” Naunheim says. “Unless we can get CMS to work with us and approve a specialty-specific APM, most surgeons will be on MIPS, and we have to prepare our membership for handling those four categories to determine whether they get a penalty or bonus.”

MIPS is so complex that it would be hard for an individual surgeon to know whether there would be a reward or punishment, he adds.

“Under the Merit-based Incentive Payment System, bonuses from Medicare will be awarded based on performance. You have to qualify based on quality measures, where there are winners and losers — a zero-sum game, without specificity for TJR,” says Richard Iorio, MD, health policy council chair for the American Association of Hip and Knee Surgeons, and chief of adult reconstruction surgery at the New York University Langone Medical Center in New York City.

“Advanced APMs could include the current bundled payment plans with some modification and are a better alternative to MIPS for adult reconstruction orthopedic surgeons,” Iorio says. (For more information on how MIPS works, see related story in this issue.)

The American College of Surgeons operates under the premise that MACRA will prevail, mostly because both political parties have a lot invested in it, Opelka says.

“Regardless of what happens to the Affordable Care Act, we’re planning and operating today as if a majority of MACRA continues,” Opelka says. “And we’re advising surgeons that in the short run, they need to be in the MIPS program and look for opportunities in the advanced alternative payment model.”

Prior to MACRA, the primary focus had been on high-cost areas, including hospital care, post-acute care, and chronic care, Opelka says.

“The federal programs have attempted to address safety, quality, and appropriateness of care in those three areas,” he explains. “Under MACRA, they’ve cast a wider net, putting all physicians under a value-based payment architecture or framework.”

MACRA adds surgery to the net, but does nothing to address medication costs, Opelka notes.

“It used to be pharma was less expensive than physician services, but with slowed growth in physician services and accelerated pharma growth, medication costs far exceed physician expenditures in the program,” he says.

As of late February 2017, the Trump administration had not deleted or canceled any specific ACA programs, but there was an executive order pertaining to MACRA, Naunheim notes.

“An executive order that Trump just put out mandated that all federal regulatory agencies minimize the negative impact of the ACA on institutions,” he says. “It was a broad order with no specified details, so we don’t know whether or not they will cancel any of the MACRA rules.”

The executive order about the ACA suggests the Trump administration is hesitant to endorse many of the Obama administration policies, Naunheim notes.

“We have to prepare for all different eventualities,” he says. “As a society, we are continuing on that pathway, and we’re working on alternative payment methodologies.”

The healthcare industry has spent years transitioning from a fee-for-service model to a value-based or quality-based payment model. The latter favors a focus on population health and bundled payments, and it seems unlikely it will return entirely to fee-for-service, even if the ACA’s financial incentives dry up, he says. (For more information on the challenges of repealing ACA, see story in this issue.)

“Whether the Trump administration allows that shift to progress and continue is uncertain,” Naunheim says. “And that’s what MACRA is really aimed at — switching from a fee-for-service model to a value-based quality model.”

If the transition to value-based care continues under the Trump administration, then it is possible physicians will be given more flexibility and opportunities.

The new secretary of Health and Human Services (HHS), Tom Price, MD, was an orthopedic surgeon before he was a congressman. Price is in favor of limiting the reporting demands of the ACA, making value-based payment methodologies voluntary, empowering physicians to take control of the episode of care, and moving more surgeries into same-day or limited-stay surgery situations, including new physician-run, small orthopedic specialty centers, Iorio says.

“Trump and Price preach about surgeon empowerment, and they think that physicians can manage bundled care better than hospitals and health plans, and they’ll do everything they can to empower physicians and allow them to innovate, improve outcomes, and cut costs,” Iorio says. “They’ll be in favor of any program that allows that to happen.”