QPP General Overview
The Quality Payment Program (QPP) was introduced by the Centers for Medicare and Medicaid Services (CMS) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which officially took effect on January 1, 2017. Its core purpose was to replace the Sustainable Growth Rate (SGR) system with a value‑based payment framework where clinicians were rewarded for higher-quality care versus the volume of services provided.
Some of the primary themes in this Proposed Rule are:
- The Merit-based Incentive Payment System (MIPS) is being held in a relatively constant position to help facilitate a transition to MIPS Value Pathways (MVPs) and to ensure a smooth re-entry into the program for those clinicians who have been filing exceptions for Extreme and Uncontrollable Circumstances for the past several years.
- It appears the future of the Quality Payment Program will include fewer choices of quality measures and improvement activities, as well as greater competition of like specialties. A prime example is the introduction of the Ambulatory Specialty Model (discussed below in greater detail).
- There will be a continued emphasis on data extraction for reporting, e.g. the Fast Healthcare Interoperability Resources (FHIR), a set of rules and specifications for the secure exchange of electronic health care data.
- Measuring patient outcomes will remain a focus.
- Comparing like specialties and including as many providers as possible in the program will remain a priority.
The Merit-based Incentive Payment System (MIPS)
Performance Threshold & Category Weights
- Performance threshold stays at 75 points through the 2026–2028 performance periods.
- Category weights for MIPS (2026 performance/2028 payment year):
Quality Measures
- The quality measure inventory is reduced to 190 quality measures (QCDR measures are not included) with five new measures, the removal of eight measures, and changes to 32 existing measures.
- 19 quality measures are identified as “topped-out” with a reduction in their point values.
Cost Measures
- No new cost measures are being introduced.
- The criteria for removing a clinician and their candidate events from attribution under the Total Per Capita Cost (TPCC) measure will be modified as follows:
- CMS is proposing to remove clinicians and their candidate events from attribution for the TPCC measure if a clinician is:
- an advanced care practitioner (that is, Nurse Practitioner, Physician Assistant, Certified Clinical Nurse Specialist), and
- part of a clinician group where all other non-advanced care practitioners (ex. radiologists) are excluded based on specialty criteria.
- The current methodology only excludes clinicians and their candidate events if a clinician meets service category thresholds for billing certain services (that is, global surgery, anesthesia, therapeutic radiation, or chemotherapy services) or if the specialty code on a clinician’s Medicare Part B claims is one of the specialties excluded from TPCC attribution. The current methodology does not exclude advanced care practitioners from attribution based on their specialty, which is identified by the specialty code on their Medicare Part B claims. This proposed modification would exclude advanced care practitioners from attribution if all other non-advanced care practitioners in their TIN are excluded based on the specialty exclusion criteria.
- CMS is proposing to remove clinicians and their candidate events from attribution for the TPCC measure if a clinician is:
- Any new cost measures will be subject to a two-year informational-only feedback period before scores are impacted.
Improvement Activities
- There are three new activities, seven activities have modifications, and eight have been removed.
- The subcategory “Achieving Health Equity” is removed and will be replaced with “Advancing Health and Wellness”
MIPS Value Pathways (MVPs)
- Six new MVPs are proposed for 2026: Diagnostic Radiology, Interventional Radiology, Neuropsychology, Pathology, Podiatry, Vascular Surgery
- There are modifications to all 21 existing MVPs
- QCDRs and Qualified Registries will have up to one year after the proposed new MVPs are finalized to support new MVPs.
- Clinicians must register to report an MVP sometime between April 1 – Dec 1, 2026 and this is easily done via the clinician’s QPP account.
- There is no penalty for registering for an MVP and then choosing to report on traditional MIPS only.
- Clinicians can choose to report under both traditional MIPS and an MVP and CMS will award the higher of the two scores.
- Subgroup reporting is mandatory beginning in 2026; however, clinicians may define a subgroup as providers with a “single focus of care.” For example, a practice that includes both diagnostic and interventional radiologists may define themselves as having a single focus of care if the interventionalists interpret some diagnostic studies such as CT exams.
- CMS has yet to finalize how “multi-specialty” group will be defined and is still seeking shareholder comments.
Advanced APMs / QP Status
- CMS is proposing to add the determination of QP status at the individual NPI level so clinicians who qualify at either the APM level or the individual NPI level will be Qualifying Participants (QPs).
The thresholds for determining QP status will remain the same as in 2025; however, all covered services will be included in the analysis versus the current methodology which considers only Evaluation and management services
Ambulatory Specialty Model (ASM)
The Ambulatory Specialty Model (ASM) is a new mandatory five-year payment model that targets specialists who treat heart failure or low back pain. The ASM is a healthcare delivery approach that is focused on providing specialized medical care in an outpatient (ambulatory) setting, versus in a facility inpatient setting. The focus of the program is the management of complex or chronic conditions that require a specialist’s expertise, but not necessarily an inpatient hospital stay. Care is delivered by specialists and those that are included in the initial “roll-out” of the program are anesthesiologists, Interventional pain management specialists, neurosurgeons, orthopedic surgeons, pain management specialists, and physical medicine and rehabilitation specialists.
This model will begin on January 1, 2027 and will extend through Dec 31, 2031 (payment years will begin in 2029). Eligible clinicians will be evaluated on quality, cost, care improvement, and interoperability and payment adjustments will range from –9% to +9%, based on clinician performance. The program’s concept is the integration of value-based care that supports quality improvement, cost control, and population health outcomes. Metrics such as readmission rates, clinical outcomes, and patient satisfaction will be a key component as will the utilization of EHRs, telemedicine, remote patient monitoring, and clinical decision support tools. The specialist care team may include nurse practitioners, physician assistants, dietitians, social workers, and pharmacists.
Goals of the ASM model include reduced hospital admissions and emergency department use, improved patient outcomes and satisfaction, lower overall healthcare costs, and easier access to specialist care, especially with telehealth integration.
Shared Savings Program (ACOs)
Expect some changes to the Shared Savings Program (ACOs) including:
The one-sided basic track duration will be shortened to five years for new agreements that start in 2027. The goal is to encourage two-sided risk participation. ACOs must have 5,000+ assigned Medicare FFS beneficiaries in Benchmark Year Three and there will be special provisions for fewer numbers in the early years; however, smaller ACOs will have their shared savings/losses capped.
CMS is proposing a) the removal of the health equity adjustment from quality scores and renaming it the “population adjustment” and b) modifying beneficiary eligibility for clinical quality measures to reduce the reporting burden.
Timeline & Comment Period
The Proposed Rule was published in the Federal Register on July 16, 2025 and the 60-day comment period closes on September 12, 2025 at 5 PM EDT. Stakeholders may submit their comments in one of three ways (reference file code CMS-1832-P):
- Electronically. https://www.regulations.gov/. Follow the “Submit a comment” instructions.
- Through the USPS: Mail to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1832-P, P.O. Box 8016, Baltimore, MD 21244-8016. Be sure to allow sufficient time for mailed comments to be received before the close of the comment period.
- By express or overnight mail. Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1832-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
Barbara Rubel
MBA, FRBMA
Senior Vice President, Marketing & Client Services
Barbara has been a leader with MSN Client Services since 1998. Her extensive background in strategic planning, market research, healthcare marketing and managed care negotiations provides a wealth of information to support MSN Clients.
Barbara has also been highly involved in industry organizations, serving as President of the Radiology Business Management Association (RBMA), the Georgia RBMA, and the Florida RBMA. In addition, she chaired the influential RBMA Federal Affairs Committee and the RBMA Technology Task force and was a member of the RBMA Data Committee. Her work on behalf of radiology has earned her the RBMA Special Recognition Award (2010), the RBMA Global Achievement Award (2013), and she is a Fellow of the RBMA.
Diana Stillwell
MHSA, CPHQ, CNMT
MSN Director, Quality Payment Programs & QCDR
Diana Stillwell, MHSA, CPHQ, CNMT, brings a wealth of experience to her position as MSN Director of Quality Payment Programs & QCDR. She worked on the clinical side of the business as a technologist and supervisor for more than 21 years and served nearly 7 years as a radiology practice director of quality improvement and risk management before joining MSN almost three years ago. She works closely with MSN senior leaders and client managers on the MIPS team to provide guidance and education to client practices with the goal of improving their reporting processes and optimizing performance in the MIPS program. In addition, she collaborates with MSN’s coding leaders to implement and/or edit workflow processes for new and modified measures.
