Saint Louis University Journal of Health Law & Policy

Document Type



This article traces the evolution of Medicare physician payment policy from the program’s beginning to the passage of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA). Based on interviews, primary data sources, and an extensive review of the secondary literature, the authors provide an analysis of: (1) some of the most significant events, trends and factors that led to the Act’s passage, (2) MACRA’s basic design and the primary options it gives to physicians, and (3) the major concerns many physician representatives and health policy experts have about MACRA. As the majority of physicians will likely feel the need to join big medical groups in response to MACRA’s set of penalties and incentives, the authors conclude that MACRA essentially amounts to a massive gamble on the ability of large health care organizations and pay-for-performance schemes to improve the quality of patient care and restrain the overall rate of Medicare cost growth. MACRA’s contribution to the trend of increased vertical integration—physicians’ alignment with and employment in big health care systems that provide an entire continuum of care—raises concerns noted by many experts over: increased health care prices and total costs, excessive use of medical services, patients’ access to physicians, overall physician autonomy and morale, and decreased competition with the potential for monopolistic or oligopolistic exploitation of market share by larger and larger health care systems.