It’s been a week since the Centers for Medicare & Medicaid Services unveiled the MACRA final rule and one thing is clear: It’s a complex new Medicare payment system with which physicians will have to grapple.

The initial relief from some health industry leaders--based on the fact the government had addressed some major concerns of physician advocates in the final rule released last Friday and built in more flexibility--is now tempered by reality as people have had time to digest the almost 2,400 pages.

“I predict the implementation process will be a nightmare,” writes Kip Sullivan, J.D., on the Health Care Blog. “The most fundamental problem with the rule is its insane complexity.”

“Yes, it’s complicated,” said David Introcaso, Ph.D., the AMGA’s senior director for regulatory and public policy, in an email to FiercePracticeManagement. Introcaso had just spent days analyzing the final rule implementing the Medicare Access and CHIP Reauthorization Act in preparation for a webinar Thursday to try and make sense of the regulations for its members.

The hour-long presentation by Introcaso and his colleague Darryl Drevna made it clear just how convoluted the new payment system is. But if there is good news, it is that CMS' “pick your pace” option lets physician practices ease into its Quality Payment Program under one of its payment tracks, the Merit-based Incentive Payment System (MIPS).

Despite the complexity, “CMS will allow very or, exceptionally minimal, MIPS reporting at least in 2017, such that providers have a good deal of time to digest/learn the new payment update paths,” Introcaso told FiercePracticeManagement.

Writing in Forbes, Grace-Marie Turner, president of the Galen Institute, a non-profit research organization focused on health policy, says the final rule implements “what is likely the most complex clinician payment program in Medicare’s history.”

“While the final rule [still open to comments for 60 days] softened some of the provisions from the proposed version, the compliance requirements are onerous,” she writes.

Along with MIPS, MACRA offers physicians another payment path, Advanced Alternative Payment Models (APM). Both, however, “create a difficult choice between two equally unappealing sub-sections,” write Barry Koslow and Dennis M. Sexton of MKA Executive Planners, a Massachusetts-based benefits and retirement planning firm, in Physicians Practice. Those APMs require providers to assume risk, they point out.

While many worried that MACRA, as outlined in an initial proposed rule that came out last April, would hurt small practices, Koslow and Sexton warn that worry does not go away with the final rule.

“Some have stated that MACRA will be a death knell for solo practitioners. While reports of their death have been greatly exaggerated in the past, the embellishment is getting less far-fetched by the minute, as the proposed regulations seem to suggest that there clearly is strength in numbers,” they write.