ASA Offers Recommendations in Support of Congressional Action to Reform MACRA

The American Society of Anesthesiologists (ASA) recently submitted comments to the House GOP Doctors Caucus and the Democratic Doctors Caucus addressing ongoing Congressional efforts to address Medicare payment issues and models. ASA remains optimistic that a bipartisan group of legislators can address many of the shortfalls of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation. Anesthesiologists and their practices often have limited opportunities to participate in Alternative Payment Models while those participating in the Merit-based Incentive Payment System (MIPS) struggle to find value or financial benefits through the program. ASA proposed more sweeping reforms for Congress to consider.

In ten years since MACRA was passed, anesthesiologists continued to see their payments diminishing in value. ASA’s first Congressional payment priority for MACRA, Alternative Payment Models, and MIPS are focused on Congress passing an annual payment update anchored in an inflation index for physician payments. The lack of an inflation adjuster in Medicare Part B is not consistent with inflation adjusters used in Medicare Part A (hospital payments) and Medicare Part C (Medicare Advantage). 

ASA also expressed our concern with recent models proposed by the Center for Medicare & Medicaid Innovation (CMMI). CMMI’s original statutory purpose was to “test innovative payment and service delivery models to reduce program expenditures … while preserving or enhancing the quality of care furnished to individuals.” ASA expressed opposition to the Ambulatory Specialty Model (ASM) that was largely built upon the flawed Merit-based Incentive Payment System (MIPS) framework. ASA noted ASM does not transform how services are paid for or delivered under Medicare, nor does it provide any new tools or flexibilities that would enable specialists to meaningfully enhance quality of care. Any projected savings under ASM are not the result of improved efficiency or care transformation, but rather stem from CMS’ decision to withhold a portion of physician payments, including select anesthesiologists and pain medicine physicians, from redistribution. ASA requested Congress to use its authority to pause the Ambulatory Specialty Model (ASM) proposed until at least 2028 to allow CMS to better define the model and understand the limitations and increased burdens ASM presents of anesthesiologists and other specialties.

ASA opposed the roll out of the Wasteful and Inappropriate Service Reduction (WISeR) Model until its Gold Card Program is implemented. Similar to ASM, WISeR is not testing innovative approaches to Medicare payment or service delivery, the statutory intent of CMMI model tests. Instead, WISeR is a punitive framework that increases administrative burden on physicians to comply with unnecessary prior authorization requirements. Anesthesiologists and their groups, especially those within the six states  where WISeR was implemented on January 1, 2026 should monitor their workflows and burden over the next few months and notify ASA of any challenges faced. 

ASA offered other solutions for repairing the flaws within both the APM and MIPS sections of MACRA legislation. For APMs, ASA recommended Congress:

• Lower Qualifying APM Participant (QP) thresholds to ensure that anesthesiologists and other specialists have an opportunity to qualify as QPs in an Advanced APM.
• Increase the bonuses and payments for physicians participating in Advanced APMs.
• Direct CMS to include provisions within an APM to accept and pay for anesthesia physical status modifiers. Those modifiers indicate more complex and intense care provided to beneficiaries and are meaningful to patients, anesthesiologists, and surgeons as well as in health system resource allocation and planning initiatives.
• Require CMMI-developed models define participants as physicians or their groups.

Within the MIPS program, anesthesiologists have struggled to earn sufficient bonuses to cover the costs of operating a quality program. Over the last ten years, MIPS has become more burdensome to practices to participate while the chances of receiving a negative adjustment have grown. ASA recommended Congress rethink the MIPS program and consider sweeping changes to how it is implement. ASA recommended Congress:

• Allocate funds rewarding exceptional performance to expand opportunities for physicians and their groups to earn sufficient revenue to cover the costs of participating in any federal quality payment program.
• Continue the use of and policy regarding thresholds for mandatory and voluntary participation currently used in MIPS in any future federal quality payment program.
• Implement a pay-for-reporting incentive. The current system that rewards “high quality” unintentionally results in physicians and groups choosing to report measures where their performance can top out quickly instead of new measures that may drive innovative practice and recent advancements in medicine and patient care.

For further information, please contact ASA Quality and Regulatory Affairs at [email protected].