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LUGPA Policy Brief: LUGPA Comments to the House Doctors Caucus on MACRA Reform and Challenges Facing Independent Urology Practices

January 2026

At-a-Glance Essentials

What’s Changing
The House Doctors Caucus is examining reforms to the Medicare Access and CHIP Reauthorization Act (MACRA) to address persistent payment instability, excessive administrative burden, stalled physician-led alternative payment models (APMs), and accelerating consolidation of independent physician practices.

Why It Matters
Nearly a decade after enactment, MACRA has failed to deliver predictable, inflation-responsive physician payment or workable value-based pathways. For independent urology practices—providing roughly one-third of U.S. urology care—these failures are driving consolidation, shifting care to higher-cost hospital settings, increasing Medicare spending, and reducing patient access, particularly in rural and underserved communities.

LUGPA’s Position
MACRA reform must stabilize physician payment, meaningfully reform or replace MIPS, accelerate the adoption of physician-focused payment models, establish site-neutral reimbursement for drugs and procedures, and codify modernizations to Stark and Anti-Kickback to preserve independent, community-based care and generate Medicare savings.

Action Needed
Congress should enact targeted MACRA reforms to stop statutory payment cuts; modernize payment updates; require testing of physician-focused APMs; repeal or overhaul MIPS’s zero-sum structure; address site-of-service inequities; and codify value-based care flexibilities.

Overview

In January, LUGPA submitted formal comments to Representatives Greg Murphy, MD, and John Joyce, MD, co-chairs of the House Doctors Caucus, in response to their request for physician input on MACRA reform. LUGPA’s comments highlight structural flaws in MACRA’s design and implementation that disproportionately harm independent practices and undermine the law’s goals of value-based care, cost containment, and patient access.

The Problem with MACRA Implementation

Nearly ten years after enactment, MACRA has not achieved its intended outcomes:

  • Unstable physician payment: Reimbursement has failed to keep pace with inflation and rising practice costs, while hospitals continue to receive annual market basket updates.
  • MIPS burden without value: MIPS imposes significant reporting costs with little evidence of quality improvement, functioning as a budget-neutral, zero-sum program with limited upside.
  • Stalled physician-focused APMs: Of 40 models submitted to PTAC, 18 were recommended, yet none have been tested or implemented by CMS.
  • Persistent site-of-service disparities: Medicare pays hospitals two to three times more for identical services delivered in physician offices or ASCs, incentivizing consolidation and higher-cost care.

These failures are accelerating consolidation, reducing competition, and increasing costs for Medicare beneficiaries and taxpayers.

LUGPA’s Key Policy Recommendations

I. Reform MPFS Updates

  • Prevent recurring statutory payment cuts, including sequestration and PAYGO.
  • Replace short-term fixes with predictable, inflation-responsive updates reflecting the cost of care.

II. Strengthen Physician-Focused Payment Models

  • Increase independent physician input in APM development.
  • Require CMS to test PTAC-approved models across diverse settings.
  • Encourage CMMI to adopt physician-designed payment innovations.

III. Repeal or Fundamentally Reform MIPS

  • Eliminate MIPS’s budget-neutral, winner-loser structure.
  • Reauthorize and expand the $500 million exceptional performance bonus pool.
  • Refocus quality measurement on outcomes while significantly reducing reporting burden.

IV. Establish Site-Neutral Payments

  • Equalize Medicare payment for Part B drugs and outpatient procedures across sites of care.
  • Reduce incentives for consolidation and care migration.
  • Generate Medicare savings—estimated by CBO at nearly $157 billion over 10 years—that can be reinvested in payment stability.

V. Codify Stark and Anti-Kickback Modernizations

  • Protect value-based arrangements, care coordination, and aligned risk sharing.
  • Reduce regulatory uncertainty while maintaining strong program integrity safeguards.

Impact on Independent Urology Practices

Independent urology practices operate on thin margins and rely heavily on office-based services. MACRA’s shortcomings have direct consequences:

  • Payment instability: Despite a 2.5% conversion factor increase in 2026, cumulative under-updates and RVU changes continue to erode viability.
  • Administrative burden: MIPS compliance exceeds $12,000 and 200 hours per physician annually, diverting time from patient care.
  • Limited APM access: Hospital-centric models marginalize independent specialists.
  • Site-of-service inequities: Higher hospital payments drive acquisitions, increase cost sharing, and threaten access—especially in rural areas.
  • Regulatory barriers: Outdated fraud and abuse laws hinder care coordination and value-based investment.

Absent reform, consolidation will continue, shifting care to higher-cost settings and limiting patient choice.

Conclusion

LUGPA applauds the House Doctors Caucus for prioritizing independent medicine and securing temporary payment relief. However, durable MACRA reform remains urgently needed.

Stabilizing physician payment, modernizing quality programs, accelerating physician-focused APMs, establishing site-neutral payments, and codifying value-based care flexibilities will preserve community-based care and deliver substantial Medicare savings without compromising quality.

LUGPA stands ready to work with Congress to advance these reforms and ensure a sustainable future for independent urology practices and their patients.