White Paper on MACRA: Past, Present and Future

The U.S. health care system is undergoing significant change as demands to improve medical quality and reduce health care costs expand. U.S. health care spending accounted for 16.9% of gross domestic product in 2013, the highest amount compared to other developed countries. On April 16, 2015 the U.S. Congress passed a historical piece of bipartisan legislation, the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA). We describe the events leading up to the passage of MACRA, review the various components of MACRA and describe how MACRA will likely impact physician practices. We also suggest how best to prepare for compliance with the Centers for Medicare & Medicaid Services (CMS) MACRA final rule with comment period, which was released on October 14, 2016.

A literature review of the quality measures defined by CMS before the passage of MACRA was performed as well as a review of the current MACRA final rule (Quality Payment Program) and related CMS commentary. An expert panel of health care consultants provided guidance concerning compliance with the final rule. Furthermore, case studies are described as examples to assist the urological community in meeting the expectations of MACRA.

The Surgical Care Improvement Project process measures (current quality) for urological surgery are reviewed and their impact on surgical site infections is described. Details of MACRA and its Quality Payment Program framework, the Merit-based Incentive Payment System and Alternative Payment Models, are also described. A detailed understanding of and preparation for the implementation of MACRA will help physicians comply with the regulations which offer future opportunities for better reimbursement. Opportunities to comply with MACRA through Advanced Alternative Payment Models may mitigate the complexity of reporting under the alternate Merit-based Incentive Payment System. The development of bundled payment procedures in urology, similar to the Comprehensive Care for Joint Replacement program in orthopedics, may eventually qualify for Advanced Alternative Payment Model status.

Physicians should be proactive, and lead the effort to improve medical quality and control health care related costs, the primary goals of MACRA. Academic and community urologists should collaborate and define optimal quality measures that are meaningful and relevant to the practice of urology, which is currently being done by the AUA (American Urological Association) Quality Registry program. The specialty of urology would benefit from a concerted effort to develop bundled payment models for a variety of urological procedures and seek CMS recognition as qualifying for Advanced Alternative Payment Models.