Introduction

This past decade has brought important change to the delivery of healthcare in the United States. In 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA, also referred to as ACA or Obamacare) into law.1 The ACA sought to provide insurance for millions of additional Americans while simultaneously bending the cost curve down.2 Beyond that, the far-ranging law imposed new taxes, developed new independent agencies with heightened power in shaping healthcare policy and regulations, and advanced the implementation of accountable care.3–5

In response to the Congressional vote passing the ACA along strict party lines, Republicans have repeatedly emphasized their desire to undo the legislation and replace it with something they considered better. The Republican Congress subsequently undertook multiple votes to repeal the ACA throughout the remainder of the Obama administration. Nonetheless, even if successful in passing Congress, all such efforts were guaranteed to be vetoed by the President.

In January 2015, Secretary of Health and Human Services Sylvia Burwell described the administration’s priority of transitioning volume-based care to a system providing greater value,6 7 and a whole new industry was formed to manage this transition.8 9 Throughout this period, a legion of other regulatory issues was confronting healthcare practitioners, ranging from ICD-10 implementation to meaningful use.10 One such perennial issue was the need to implement a fix to prevent enormous cuts to Medicare payments resulting from the sustainable growth rate formula for Part B services.11 12 In April 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed, permanently ending the sustainable growth rate.13 14 However, MACRA, which has been described in numerous dedicated reviews,15 16 introduced an array of new challenges for providers, beneficiaries, and payers alike.17 18

It is generally agreed …