On July 10, 2025, CMS released the CY 2026 Medicare Physician Fee Schedule (PFS) Proposed Rule. While CMS characterized 2026 as a “stabilization year,” the Proposed Rule brings several notable updates to the Merit-Based Incentive Payment System (MIPS), particularly around MIPS Value Pathways (MVPs), the Cost performance category, and registry participation.  

These changes are crucial for providers aiming to protect their reimbursement, streamline reporting, and improve performance. 

Key proposed changes in the 2026 PFS Rule for MIPS 

CMS proposes maintaining the MIPS performance threshold at 75 points through the 2028 performance year. This provides continuity and predictability for clinicians. 

Impact 
The 75-point threshold isn’t trivial. Practices must maintain strong performance across the Quality, Cost, Promoting Interoperability, and Improvement Activities performance categories to avoid penalties. For many, this requires deeper integration of quality reporting with clinical workflows.

2. No new cost measures, but good updates to TPCC measure!

• Modifications to attribution for the Total Per Capita Cost (TPCC)  
• Continued development of episode-based cost measures 
• Introduction of 2-year informational-only periods for new cost measures

Impact

Fewer providers will have the TPCC measure attributed to them 🎉. Clinicians will also receive feedback on new cost measures without penalty for 2 years. This offers an opportunity to analyze attribution, care patterns, and areas for efficiency before cost scores affect reimbursement. Clinicians will, however, need access to meaningful analytics to take advantage of this window. 

MVPs are the future of MIPS.  CMS is expanding the MVP framework by proposing 6 new MVPs: 

• Diagnostic radiology 
• Interventional radiology 
• Neuropsychology 
• Pathology 
• Podiatry 
• Vascular surgery 

This would bring the number of MVPs to 27, providing more specialty-specific pathways for clinicians to align their reporting with their practice. These MVPs are designed to provide more meaningful and clinically relevant performance feedback. 

Impact 
Providers in newly covered specialties will have access to tailored MVPs that better reflect their practice. This can improve performance scores but will require upfront education and onboarding. Groups should begin identifying which clinicians qualify and prepare to implement MVP reporting workflows.

4. Revisions to all 21 existing MVPs

CMS is proposing modifications to all 21 previously finalized MVPs. Updates include: 

• The addition or removal of quality measures based on new measure validity and alignment 
• Clarified improvement activity and cost measure inclusion 
• Updated population health measures in some MVPs 
  
  Impact
  Even if you’re already using an MVP, your requirements may change in 2026. Practices must review changes to ensure continued compliance. This may require retraining, updates to data feeds, and re-evaluation of subgroup strategies.

5. Subgroup reporting clarifications

CMS is proposing that multispecialty groups with 25-plus clinicians must use subgroup reporting in MVPs starting in 2026. Smaller groups may continue to report at the group level. 

Impact 
Large multispecialty groups must operationalize subgrouping workflows immediately, including: 

• Identifying clinician subgroups by specialty 
• Mapping each subgroup to a relevant MVP 
• Ensuring distinct measure sets and data collection workflows for each subgroup 

This adds complexity, especially for organizations not using centralized data systems.

6. Promoting Interoperability updates

• Optional new measure for reporting participation in the Trusted Exchange Framework and Common Agreement (TEFCA) 
• Continued suppression of the electronic case reporting (eCR) measure due to onboarding delays 

Impact 
Providers can earn bonus points under PI for participating in emerging data exchange frameworks. Participation in TEFCA may also help meet compliance goals under other CMS or ONC programs. 

Overall strategic implications for providers 

• Avoiding penalties requires intentional planning: With the 75-point threshold holding steady, even high-performing providers need a coordinated strategy to avoid downward payment adjustments. 
• MVP adoption is no longer optional: The MVP framework is becoming the default for meaningful reporting. CMS is investing heavily in MVP expansion and subgrouping requirements. Providers who haven’t begun MVP adoption should treat 2026 as a transition year. 
• Cost measures are growing in influence: Even though CMS is offering a grace period on new cost measures, the long-term intent is clear: cost containment and accountability are increasing. Providers should start internal cost benchmarking now. 
• Vendor relationships matter: Given the evolving complexity, choosing the right QCDR or registry partner is critical. You’ll need robust analytics, flexible MVP support, and rapid adaptation to measure changes. 

Conclusion 

The 2026 Proposed Rule emphasizes continuity while nudging providers toward MVP adoption. By expanding specialty alignment, stabilizing scoring thresholds, and creating realistic timelines for adoption, CMS is balancing flexibility with forward motion. Providers who engage now by identifying MVP fits, refining subgroup strategies, and investing in performance analytics will be best positioned to thrive. 

Need help making sense of these changes or preparing your strategy for 2026? Healthmonix is here to help. Contact our team to start building your 2026 MVP and cost strategy today. 

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