CMS Is Retiring MIPS, but the Payment Math Stays Intact
Medicare is preparing to close the book on MIPS, the Merit-based Incentive Payment System, after the 2028 performance year. Beginning in 2029, MIPS Value Pathways will become the only reporting option for clinicians outside Advanced Alternative Payment Models. The federal message is easy to miss inside a 1,600-page proposed rule, but the policy direction is plain: the reporting framework is changing, while the financial logic that made MIPS unpopular remains in place.
A decade after its launch, MIPS is being phased out without a formal admission that the core premise failed. CMS built a system around the belief that a composite score assembled from a limited set of self-selected measures could distinguish high-quality clinicians from low-quality ones. The evidence never supported that idea. MedPAC called for replacing MIPS years ago, and the current proposal reads less like a correction than a relabeling.
The practical consequence is immediate for independent practices. The program may get a new name and a narrower pathway structure, but physicians will still be asked to absorb substantial reporting work for a small possible reward and a much larger possible penalty.
Quality Scores Never Matched Clinical Reality
The strongest critique of MIPS is not ideological. It is empirical.
A large _JAMA_ study of roughly 80,000 primary care physicians found that MIPS scores were inconsistently related to actual performance on process and outcome measures. Physicians caring for medically complex and socially vulnerable patients tended to score lower, which is exactly the opposite of what a quality program should do if it were faithfully measuring care. Parallel work in hospital-based clinicians found no relationship between MIPS scores and postoperative complications. The scorecard moved; clinical outcomes did not.
A program that fails to separate better care from worse care has one predictable substitute: overhead. Estimates place MIPS participation at about $13,000 per physician per year, along with roughly 200 hours of physician, clinical staff, and administrative time. Those hours are not abstract. They come from chart review, registry abstraction, measure selection, attestation, vendor coordination, and repeated internal reconciliation when submitted data do not match the reporting platform.
The burden falls hardest on practices least equipped to absorb it. CMS experience reports have repeatedly shown higher penalty rates among solo clinicians and small practices than among clinicians overall, with rural practices faring worse still. The pattern is hard to explain away. MIPS has rewarded administrative scale more reliably than clinical excellence.
Nine down, one up.
MVPs Replace Optional Burden With Mandatory Burden
CMS is proposing three new MVPs for 2027, including pathways for diabetes, hypertension, and hospitalist care, bringing the total to about 30. The diabetes and hypertension pathways mirror Medicare Advantage Star Ratings measures, particularly blood pressure and hemoglobin A1C control. That alignment has real operational value. A practice that can run one measurement workflow across Traditional Medicare and Medicare Advantage may reduce redundant tracking, duplicate quality abstraction, and vendor sprawl.
Still, the new design does not solve the central problem. It changes the shape of reporting without changing the incentive structure that makes reporting feel punitive. Traditional MIPS remains available through 2028, but the mandatory future belongs to MVPs. The option set narrows while the financial asymmetry persists.
CMS also proposes a core measure requirement. At least one reported quality measure would have to come from a designated core set, or the clinician loses the points for one required measure. Small practices would be exempt, and clinicians could attest that no core measure applies and substitute another measure. Benchmarks for those core measures would be developed specifically for the set rather than being evaluated against measures where nearly everyone already earns top marks. In principle, that could create more meaningful differentiation in performance.
Coordination Work Is Being Devalued While Outcomes Stay in Focus
The most revealing part of the proposal is not what it adds, but what it removes.
CMS is proposing to delete several Improvement Activities tied to routine coordination and continuity of care, including glycemic screening and referral services, care-transition documentation, care-transition operational improvements, care coordination agreements for tracking patients across settings, bilateral electronic exchange of information between primary care and behavioral health, engagement of patients and caregivers in care planning, depression prevention and treatment interventions, and anticoagulant management.
In their place, CMS proposes activities such as use of data to improve workflows, understanding and improving diagnostic performance, systematic screening for nutrition and other nonclinical needs, advance care planning conversations, lifestyle approaches to diabetes remediation, and clinician use of artificial intelligence to improve patient care.
The substitution reveals the agency’s priorities. It wants outcome measures like blood pressure and glucose control, but it is withdrawing credit for many of the mundane, operational tasks that make those outcomes possible. A patient does not achieve control through aspiration alone. Medication reconciliation, cross-setting communication, behavior change support, and reliable follow-up are the machinery underneath the numbers. When the program stops rewarding that work, practices may do less of it, or they may keep doing it without receiving recognition for the labor involved.
Prior Authorization Becomes a Reporting Obligation
The new electronic prior authorization measure is one of the clearest signs of where this program is heading. CMS would require clinicians to attest that they submitted at least one prior authorization through a payer application programming interface using certified EHR technology. The measure begins as a modest bonus in 2027 and becomes mandatory in 2028, with a companion prescription-drug measure to follow.
That structure puts the burden on the clinician side of a process that depends on payer infrastructure. Payers are being asked to build the pipe; clinicians are being scored on using it. Certified EHR upgrades are not free, and the rule does not guarantee a favorable or timely decision on the other end of the transaction. The result is another compliance obligation layered onto practices that already spend heavily just to remain eligible.
The proposed removal of the security risk analysis attestation from Promoting Interoperability follows a similar pattern. The HIPAA obligation remains, but the checkbox disappears. Vendors will still have to address security. Practices will still bear the liability.
Independent Practices Face the Sharpest Edge
The hardest part for independent clinicians is not simply the reporting burden. It is the changing access to the only real escape hatch.
Qualifying Alternative Payment Model participation remains the clean way out of MIPS. If enough Medicare revenue or patient volume runs through an Advanced APM such as the Medicare Shared Savings Program or a CMS Innovation Center model, a clinician becomes a Qualifying APM Participant, avoids MIPS reporting, and receives the higher conversion factor. As the qualification threshold becomes harder to reach, more clinicians will fall back into the mandatory MVP structure.
Physicians who split time across practices lose portability in a system that increasingly rewards organizational scale. The practices best positioned to cope are the largest ones, with analytics staff, compliance infrastructure, and enough patient volume to spread fixed costs. Small and solo practices, which already face disproportionate penalty exposure, remain on the weak side of the ledger.
MVP adoption has also been slow when it was optional. Out of hundreds of thousands of eligible clinicians each year, only a small share selected an MVP, and fewer still completed the pathway so that the final score came from it. Beginning in 2029, the optional path disappears. The program most clinicians declined voluntarily becomes the only route forward.
What Practices Need to Do Before 2029
The safest move is not to wait for the mandatory switch.
Practices should select an MVP in 2027 rather than waiting until 2028, when traditional MIPS is still available as a fallback but the learning curve will already be compressing toward the penalty year. Practices near the qualifying threshold for an ACO or other Advanced APM should examine whether they can clear it, because the difference between qualifying and missing is the difference between avoiding MIPS entirely and entering the mandatory MVP track.
Care coordination should not be abandoned simply because CMS has stopped counting it in the same way. Patients still transition between clinicians, hospitals, behavioral health settings, and post-acute care. Readmissions do not disappear when a measure is removed.
The final rule is expected around November, and the 2028 policy cycle will be the last realistic chance to shape the mandatory MVP structure before it binds. The central problem remains unchanged: a program that could not measure quality well is being repackaged rather than rebuilt, with a 1% upside and a 9% downside still doing the work of forcing compliance.