Medicare’s MIPS program: 10 years, 200 hours a year and a 1% tip

The Centers for Medicare & Medicaid Services (CMS) has proposed putting traditional MIPS, the Merit-based Incentive Payment System, to rest after the 2028 performance year. The replacement is being built by the same people, on the same premise, with the same math.

Buried deep in the 1,600 or so pages of the CY 2027 Medicare Physician Fee Schedule proposed rule is the closest thing to an admission of failure that CMS is institutionally capable of producing. Traditional MIPS sunsets after the 2028 performance year. Beginning in 2029, MIPS Value Pathways (MVPs) will become the only reporting option for any clinician not sheltered inside an Advanced Alternative Payment Model (APM).

Read that as a concession. For a decade, CMS built, defended and repatched a program premised on the idea that a numerical score assembled from a handful of self-selected measures could distinguish a good physician from a bad one. The agency is retiring that program without ever conceding that the premise was wrong. MedPAC, the Medicare Payment Advisory Commission, told them it was wrong back in 2018, recommending flatly that Congress eliminate MIPS and replace it with a voluntary, group-level value program. That was eight years and an enormous number of uncompensated physician hours ago.

What the evidence actually showed

The most substantial look at MIPS in primary care — published in JAMA, covering roughly 80,000 primary care physicians — found that MIPS scores were inconsistently related to actual performance on process and outcome measures. Worse, physicians caring for more medically complex and socially vulnerable patients tended to score lower. Parallel work on hospital-based clinicians found no relationship between MIPS scores and postoperative complications.

So the program did not measure quality. What did it measure? Overhead. Published estimates put participation at roughly $13,000 per physician per year, consuming on the order of 200 hours of physician, clinical and administrative staff time. That is not a quality program. That is a compliance tax with a scorecard attached.

And it was a regressive tax. CMS' own experience reports have shown, year after year, that roughly half of solo clinicians and close to a third of clinicians in small practices were penalized, against well under 15% of eligible clinicians overall. Rural clinicians fared measurably worse. The program most reliably identified not the physicians delivering worse care, but the ones without a compliance department.

The asymmetry nobody defends out loud

MIPS is budget-neutral, which sounds fiscally responsible until you see what budget neutrality produced. In recent payment years, a perfect score of 100 has earned a positive adjustment of roughly 1% — the smallest upside in the program's history — while a failing score still carries the full statutory 9% penalty.

Nine down, one up. Spend $13,000 chasing 1%. That is the arithmetic a solo family physician has been asked to accept for 10 years, and it is why "value-based care" now produces an eye roll in any room containing more than two independent physicians. The performance threshold, incidentally, stays parked where it is through 2028. Nothing about the asymmetry is proposed for repair. Only the reporting architecture is being replaced.

The replacement, examined

Three new MVPs are proposed for 2027 — diabetes, hypertension and hospitalist care — bringing the total to about 30. The diabetes and hypertension pathways mirror Medicare Advantage Star Ratings measures: blood pressure control, hemoglobin A_1C control. That alignment is genuinely the best thing in the rule, and I will say so plainly. A practice running one quality workflow across Traditional Medicare and its MA contracts instead of four is a real efficiency gain.

CMS also proposes a core measure requirement: At least one reported quality measure must come from a designated core set, or you forfeit the points on one of your required measures. Small practices are exempt, and any clinician can attest that no core measure applies and substitute another. Under the revised approach, core measures would be scored against benchmarks developed specifically for them, rather than against measures on which nearly everyone already earns top marks. This change would make MIPS scores better reflect meaningful differences in clinical performance, instead of rewarding practices for clearing a bar that most have already reached.

Then look at what the same rule takes away, and what it puts in its place. The Improvement Activities proposed for deletion include:

• glycemic screening services and glycemic referring 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 for shared patients
• engagement of patients and caregivers in developing a plan of care
• depression prevention and treatment interventionsanticoagulant management.

The Improvement Activities proposed to replace them include:

• use of data to improve practice workflows
• understanding and improving diagnostic performance
• systematic screening for nutrition and other nonclinical needs
• advance care planning conversations
• lifestyle approaches to diabetes remediation
• clinician use of artificial intelligence to improve patient care

Set the two lists side by side. CMS is proposing a diabetes MVP while deleting credit for glycemic screening and referral, offering "lifestyle approaches to diabetes remediation" in trade. More broadly, it is measuring outcomes like blood pressure and blood glucose control while withdrawing credit for much of the day-to-day coordination that produces those outcomes. The specific, documented work of moving a patient between clinicians is out. Broader activities, including the adoption of new technology, are in. What CMS wants to measure has gotten more precise. What it is willing to reward has gotten vaguer.

The security risk analysis requirement, meanwhile, is proposed for removal from Promoting Interoperability. Note carefully that it remains mandatory under the Health Insurance Portability and Accountability Act. Only the attestation disappears. Do not let a compliance vendor sell you the other interpretation.

The prior authorization measure is a tell

CMS proposes a new electronic prior authorization measure: attest that you submitted at least one prior authorization through a payer's application programming interface (API) using certified electronic health record (EHR) technology. It arrives as a modest bonus in 2027 and becomes mandatory in 2028, with a companion prescription-drug measure added in 2028.

This is the provider-side complement to the rule requiring payers to build those APIs. Fine in principle. But read the incentive structure honestly. The payer obligation is to build a pipe. The physician obligation is to be scored on using it, with certified EHR upgrades on your dime. Primary care is once again the party with the mandate rather than the party with the leverage. And nothing requires that the answer coming back through that API be a yes, or be timely, or be reviewed by anyone with relevant clinical training.

Independent practice impact

The part that should concentrate the mind of every independent practice leader is not in the MVP section at all.

Start with what a qualifying status actually buys you. If enough of your Medicare revenue, or enough of your patients, flows through an Advanced APM like the Medicare Shared Savings Program or CMS Innovation Center (CMMI) models, you become a Qualifying APM Participant. That designation exempts you from MIPS reporting altogether and pays you off the higher of the two conversion factors. It is the only clean exit from everything described above.

Put the two halves together. Qualifying status gets substantially harder to reach, so more clinicians fall back into MIPS — and MIPS becomes mandatory-MVP-only. Physicians splitting time across practices lose portable qualifying status because it no longer follows them.

The practices best positioned to absorb that are those with analytics staff and sufficient size to spread the math. The ones that are worst positioned are the small and solo practices already penalized at far higher rates than everyone else. This rule does nothing to change who bears the burden. It just changes the paperwork.

It is also worth asking how MVPs have done so far. CMS has offered them for several years now as an optional alternative: Instead of reporting traditional MIPS, you could pick a pathway built around your specialty and report that. Physicians were free to try one. Very few did. Out of hundreds of thousands of eligible clinicians each year, only a small share ever signed up, and fewer still saw the process through and had their final score come from an MVP.

So the option is now becoming the requirement. When physicians had a choice, they overwhelmingly declined this pathway. Beginning in 2029, it is the only one left.

What to do between now and 2029

Pick your MVP in 2027, not 2028. You get two performance years to learn a reporting pathway, while traditional MIPS remains a fallback. Report an MVP alongside traditional MIPS and keep the better score. Practices that wait until the pathway is compulsory will be learning the mechanics in the year the penalty is live.

Review how potential changes to MIPS could affect your reporting obligations and Medicare payments. If you are anywhere near the payment threshold through your accountable care organization (ACO), clearing it versus missing it is the difference between the APM conversion factor with no MIPS reporting at all, and the lower conversion factor plus a mandatory MVP. This is worth an afternoon with your ACO's finance staff.

Do not stop doing care coordination because CMS stopped counting it. Removing the Improvement Activity does not remove the readmission.

Say something, please. Comments on the 2027 rule have closed, and the final rule is due around the start of November. But the 2028 policy development cycle brings another chance to influence Medicare’s payment and reporting requirements. The 2028 cycle will be the last real chance to shape mandatory MVP reporting before it binds. Small practices are already exempt from the core measure requirement, proof that a carve-out is achievable when somebody asks for one in writing.

MIPS earned its sunset. But a program's failure is only useful if somebody names the reason for it, and the reason was never the reporting format. It was the belief that you can buy quality with a 1% bonus and enforce it with a 9% penalty, and that the physicians who score lowest must be the ones practicing worst, rather than the ones practicing alone.

New pathway, same penalty. Until CMS fixes the math, this is a remodel, not a repair. So yes, MIPS is finally over. And every physician I know is braced for what CMS is calling an improvement.

Robert Resnik, M.D., MBA, is a board-certified internal medicine physician practicing in Cary, North Carolina. He earned his medical degree from Eastern Virginia Medical School and completed his residency at East Carolina University. He also holds an MBA from Duke University.